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2p� WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS . b tr M�M6 Ile CITYZP C.i/WYQ� m <br /> CROSS STREET s APIN O V PARCEL SIZE.�LAND USE APPLICA7TION# <br /> OWNER NAME IIAI U "-' C PHONE <br /> �! �� <br /> L n l <br /> OWNER ADDRESS CITY/STATE/ZIP /L <br /> CONTRACTOR / PHONE <br /> CONTRACTOR ADDREB3 CITY/STATE21P 6tAr, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE will ❑ C-61 J D-09 ❑ Other NUMBQ 6S EXPIRATION DATE :i <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDeo USE Domestic/Private,vg_lrrigation/Agricultural ❑ Industrial J Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Public Water System <br /> ,�rIf.ciftrant from Owner: Water System Name ntacl ame or one um r <br /> TYPE OF WORK A44ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> J Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> �iwldlew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,)_'gHud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I Push Point ❑ Other <br /> Proposed Well Depth:S 30__fl Excavation 1V— In diameter �- Open Bottom rdicaravel Pack/Gravel Size In diameter <br /> _ Conduct asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 7- 20 J Steel�PlastiC J Stainless SteeL ❑ Other <br /> Grout Seal Depth ft J Neat Cement(94 lb bao-10 gal water) j* and Cement 10i sack mix/7 gal water <br /> c Bentonite(20%solids) Other <br /> Grout Placement Methotl 01%Fumped Free Fall ❑ Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width IJ it Length R Thick in Li Christy Box C Stove Pipe <br /> PUMP -+L$ubmersible❑ Turbine ❑ Other HP Pump Set it Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM 4 H URA VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697/ <br /> SIGNED TITLE OW14 r DATE <br /> t <br /> C <br /> P L <br /> C CIOU <br /> K <br /> DEPARTMENT USP ONLY <br /> Application Accepted B Data Area Employee ID# CO&6 <br /> Grout Inspection y Date / « ❑ SPECIAL Well Permit <br /> Pump inspection Date 3�151� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received e / Amount pate Permit/ Involee# Well ID# <br /> Codes Info B Cash Remittatl Service Request# <br /> v 6 -2ooloto 0 <br /> EHD 4( N WELL(PUMP PERMIT <br /> 7011 <br />