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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) 953-77697 FOR INSPECTIONS EXPII,yR,�1ES 1 YEAR FROM DATE ISSUED <br />JOB ADDRE*�' <br />SS %i/ 1 \ CITY/ZIP , 1 I <br />CROSS STREET APN (��` S/1�O/-(/OI SRCEL SIZE LAND USE APPL� ATON # <br />OWNER NAME I5 JAA) V PHONE <br />OWNER ADDRESS Z CITY/STATE/ZIP L--✓ 7,d <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR PHO <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ✓C 57 C-61 D-09 Other CJ NUMBER 14%EXPIRATION DATE -J • �� I <br />GEOGRAPHICAL INFORMATION: COordlnK5 SOOD Y @ Township _ Range Section_ <br />INTENDED USE Domestic/Private VIrrigationlAgricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Uontact Name or one um er <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well 0 -Of-Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement r/Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Dept ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched pt <br />Plastic Stainless Steel Other <br />Grout Seal Depth ft Neal Cement (94 lb 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 />Concrete Pedestal Dimensions: Width it Length ft Thick in Christy Box Stove Pipe <br />PUMP SubmersibleV Turbine Other HP dU U Pump Set ft Standing Water Level ft <br />IBY C IFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />AQUIN CCU <br />ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENTCTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERSfM NSATION LA <br />MI DVA E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953--7 7 <br />SIGNED I TITLE DATE d' <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />H <br />P <br />N <br />D <br />0 <br />m <br />N <br />AqY <br />1 <br />J° 801 <br />`4< rN'P!!ti� CO <br />F1 <br />TMENT U E O L <br />Date <br />Are Employee ID#=E� <br />Date <br />SPEC AL Well Permit <br />Date <br />J WAIVER Received <br />Date <br />Constructed Well Depth ft <br />PE SC Received Amount <br />Codes Info By. Cash Remitted <br />Date <br />Permit/ <br />Service Request # Invoice# WellID# <br />I� <br />OO <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />s <br />