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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />GALL (ZU8) 853-7687 FOR INSPECTIONS <br />LAPIKKL5 1 YEaAR FROM LATE ISSUED <br />r1e4 <br />JOB ADDRESS <br /># Well ID# <br />CITYIZIP <br />414/ 154,te le,-) <br />CROSS STREET �" / AT/Y <br />APN T-"�'T' '✓�-'B�� <br />PARCEL SIZE ilo <br />LAND USE APPLICATION # <br />OWNER NAME ✓♦: S" ­V la3- <br />PHONE <br />OWNER ADDRESS q <br />V' 0 <br />CITY/STATE/ZIP <br />CONTRACTOR C I K��n iol <br />Q <br />�T�iT� 1.4't Imo' <br />/ (, Q� % �/ <br />PHONE 1 ' /f - • 77J <br />CONTRACTOR ADDRESS �J '�O <br />A:-14 4} Me -�J" <br />CITY/STATE/ZIP <br />/,5� <br />JTZ' ^r u'✓ / S—�� -1 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITTYIISSTAATE/ZIP <br />LICENSE I C-57 �-61 1 ' D-09 I Other <br />NUMBER / / / <br />% -7 <br />EXPIRATION DATE I ; -/f <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial I Water Quality Monitoring I Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Uontact ame or ne um er <br />TYPE OF WORK I New Well I I Replacement Well Well Alteration/Modification I I Other <br />I Monitoring Well(s) # of wells Soil Boring(s) # of borings I Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />New PUmD '�®UITD Replacement PumD Repair I I Raise Well Casino <br />Drilling Method i Mud Rotary i I Air Rotary I 1 Auger I Cable Tool i Push Point I Other <br />Proposed Well Depth ft Excavation in diameter i I Open Bottom i I Gravel Pack/Gravel Size in diameter <br />I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad I I Steel I i Plastic Stainless Steel i I Other <br />Grout Seal Depth ft I Neat Cement (94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) I Other <br />Grout Placement Method I I Pumped Free Fall I Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller 1 I Pump Contractor 1 I Other <br />I I Concrete Pedestal 1 1Dimensions: Width It Length ft Thick in Christy Box : Stove Pipe <br />PUMP ubmersible I Turbine I I Other HP Pump Set /O d ft Standing Water Level ft <br />I HEREBY CEll 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 />MINIMUM 24 HOUR A C TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLEDATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DqjPARTMENpT U E NLY <br />Date 1 <br />Date <br />Date <br />Date <br />Area Employee ID#-jj:�W <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth It <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ <br />Cash <br />Amount Date Permit(Invoice <br />Remitted Service Request # <br /># Well ID# <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />I <br />