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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 />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br />D <br />CITY/ZIP <br />CITY/STATE/ZIP <br />JOB ADDRESS <br />C I b <br />//�� <br />� <br />�%� <br />CROSS STREET\Idn <br />APN 1KC71 0010 <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />GEOGRAPHICAL INFORMATION: COOrdina X <br />GEOGRAPHICAL <br />OWNER NAME <br />-ftFft�' <br />Section <br />PHONE <br />If Water Quality Monitoring <br />OWNER ADDRESS <br />Public Water System <br />CITY/STATE/ZIP <br />Dbh <br />uontad <br />Name or Flhone Number <br />74 <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />CONTRACTOR <br />Monitoring Well(s) # of wells Soil Boring(s) <br />PHONE w\ <br />Geotechnical <br />�•�/1 <br />Out -Of -Service WellqGt-Of-Service Well Renewal Cross -Connection <br />n, <br />New Pumo Pumo Reolacement JPumo Reoair <br />CONTRACTOR ADDRESS �/ <br />p <br />CITYISTATE/ZIP <br />Aix <br />SUBCONTRACTOR / <br />PHONE <br />l <br />SUBCONTRACTOR ADDRESS ( <br />CITY/STATE/ZIP <br />C I b <br />//�� <br />� <br />�%� <br />LICENSE YC -57 C-61 D-09 Other <br />UMBER -,l'-IU, <br />J EXPIRATION DATE <br />/D <br />GEOGRAPHICAL INFORMATION: COOrdina X <br />GEOGRAPHICAL <br />Lk�Jvp <br />-g Range <br />Section <br />INTENDED USE Domestic./Private rrigation/Agricultural Industrial <br />If Water Quality Monitoring <br />Soil Sampling/Characterization <br />Public Water System <br />If different from OwnerWa er System Name <br />uontad <br />Name or Flhone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) <br /># of borings <br />Geotechnical <br /># of borings <br />Out -Of -Service WellqGt-Of-Service Well Renewal Cross -Connection <br />Repair <br />New Pumo Pumo Reolacement JPumo Reoair <br />Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool - Push Point Other <br />Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant /-Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />C trete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other -H P 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 />JOAQUUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CU NT ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />IV&RKERSO PENSWS. <br />NHOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)3'7G9Li /may <br />SIGNED TITLE DATE <br />PAY <br />REQ <br />Jut <br />5" JO <br />E -WI <br />HETI <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EPA T M <br />Date S"Y4qA r/Nj�/i��Vp�/ � / � ( <br />Date � Area Employee ]D#— j� 1 �V�"' % <br />Date PEc L Well Permit <br />Date A I WAIVER Received <br />Date Constructed Well Depth ft <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />