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y. <br />WELUPUMP PERMIT <br />SAk JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS L 1, <br />CROSS STREET 1 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />13 L <br />CONTRACTOR ADDRESS GN <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 L C-61 <br />GALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />++ <br />o' `' o CITY/ZIP i <br />APN7i '-U L PARCEL SIZE AND USE APPLICATION # <br />PHONE <br />CITY/STATE/ZIP—LY`J� <br />PHONE <br />CITY/STATE/ZIP <br />PHONE <br />L' D-09 rl Other <br />CITY/STATE/ZIP <br />NUMBER 7' 4 C EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />VTENDED USE i i Domestic/Private XIrrigation/Agricultural _1 Industrial I Water Quality Monitoring Soil Sampling/Characterization <br />i Public WaterSystem <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK L New Well n Replacement Well LI Well Alteration/Modification L Other <br />Monitoring Well(s) # of wells G Soil Boring(s) If of borings r Geotechnical <br />L I Out -Of -Service Well L Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump F Pump Heplacement L <br />i Haise Well <br /># of borings <br />Drilling Method i I Mud Rotary ❑ Air Rotary i -I Auger I i Cable Tool I, Push Point II Other <br />Proposed Well Depth ft Excavation in diameter I 1 Open Bottom r 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 i i Steel Plastic i Stainless Steel I! Other <br />Grout Seal Depth ft r Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br />_I Bentonite (20% solids) D Other <br />Grout Placement Method n Pumped n Free Fall ii Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller I Pump Contractor I i Other <br />i I Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box i Stove Pipe <br />PUMP h<Submersiblel ] 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 LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CON CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH L <br />WORKERS COMPIE S, <br />MI 61 24 HO ADVANC N RED FOR EC/TIONS - PLEASE CALL (209) 953- 697 <br />SIGNED TITLE F� DATE <br />j_DJEPARTMENT U E ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By D, -.Ie <br />COMMENTS <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />1 <br />rnD <br />0 <br />M <br />m <br />m <br />rn <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />05D <br />011 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />