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WELUPUMP PERMIT P � <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />Ay <br />JOB ADDRESS f <br />CROSS STREET l <br />OWNER NAME - O <br />OWNER ADDRESS •G <br />CONTRACTOR <br />CONTRACTOR ADDRESS_ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE X C-57 I C-61 D-09 Other <br />L <br />;ALL (209) 953-7697 FOR INSPECTIONS tXNIHt_5 1 YEAR FROM UATE ISSUED <br />CITY/ZIP L "c'� Y �—) G <br />AP�%' ��V _Vli PARCEL SIZ �� LAND USE APPLICATION # <br />U CITY/STATE/ZIPCC <br />�Qf i�JV <br />VC /�qq PHONES//D I, V' <br />0.c N1� CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER I`7 1 EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural a Industrial Water Quality Monitoring I i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK I I New Well I Replacement Well I i Well Alteration/Modification I Other <br />I I Monitoring Well(s) # of wells rI Soil Boring(s) # of borings I Geotechnical it of borings <br />I Out -Of -Service Well I I Out -Of -Service Well Renewal I I Cross -Connection Repair <br />New Pump I I Pump Replacement I I Pump Repair I 1 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I , Mud Rotary I I Air Rotary Auger I Cable Tool Push Point I Other <br />Proposed Well Depth ft Excavation in diameter 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 Sched Steel I i Plastic Stainless Steel i Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) 1.1 Sand Cement sack mix/7 gal water <br />i Bentonite (20% solids) Other <br />Grout Placement Method Pumped I Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller 1 Pump Contractor I Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft 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 LA S, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIF A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C ATION LAWS. <br />INIMU 24 HOUR D C�EINOTICE REQUIRED FO ECTIONS -PLEASE CALL (209) 953- 697 <br />SIGNED TITLE DATE C <br />D P A R T M ENT S E ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By +: Date i ZO <br />Soil Boring Inspection By D,:te <br />COMMENTS <br />Area Employee ID# J4�] <br />❑ SPECIAL Well Permit <br />1 WAIVER Received <br />Constructed Well Depth ft <br />T <br />D <br />0 <br />0 <br />a <br />M <br />rn <br />a"r <br />PE <br />SC <br />Info <br />Received <br />B <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/Codes <br />Service Request # <br />Invoice # <br />Well ID# <br />3 k-7 <br />6 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />