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PV <br />WELUPUMP PERMIT <br />SAN JOAQUIN COttNTY ENVIRONMENTAL HEALTH DEPARTMENT 18G8 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-H'cFUNDABLE F'ERMII <br />JOB ADDRESS <br />CROSS STREET �r <br />OWNER NAME <br />OWNER ADDRESS D <br />CONTRACTOR t <br />CONTRACTOR ADDRESS g1�C <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 C-61 <br />L;AL/L (ZU9 9b3-1697 FOR INSPECTIONS <br />yCITY/ZIP <br />r` <br />APN 0_�-0 PARCEL SIZE -� <br />VlI &k <br />D-09 ❑ Other <br />tXF'IHt:5 1 YEAR FROM UATE ISSUED <br />USE APPLICATION # <br />PNEO-01)2f-G b- -Z V <br />,VfQ) 11A <br />CITY/STATE/ZIP w <br />PHONE <br />CITY]/STATE/ZIP <br />NUMBER + 70 V D EXPIRATION DATE � 30 - <br />GEOGRAPHICAL <br />y <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE �9_Domestic/Private ❑ Irrigation/Agricultural Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name ontact ame or one Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) If of borings ❑ Geotechnical # of <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal _-1 Cross -Connection Repair <br />K New Hump rump He lacement ❑ VUITIP He air _1 Hatse Well Gasin <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary j 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 Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad [ISteel 11Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth It ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method i Pumped ❑ Free Fall ❑ Other i Retardant/Accelerator (name) <br />PEDESTAL Installed By Driller I Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HPPump 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 CALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WIT7 ALL <br />WORKERS COMPENSATION LAWS. <br />',,�NNIMU�UA E NOTICE REQUIRED F ECTIONS - PLEASE CALL (209)953- <br />SIGNED/ TITLE: DATE _ f 4 <br />AreaEmployee I <br />11PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rn <br />m <br />m <br />D <br />0 <br />a <br />m <br />U) <br />U) <br />PE <br />DEPARTMENT U E ONLY <br />Application Accepted By <br />�n V�/�. Date f/ / b <br />Grout Inspection By <br />Pump Inspection By <br />Date <br />Date <br />a Date <br />Invoice # <br />Well ID# <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />AreaEmployee I <br />11PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rn <br />m <br />m <br />D <br />0 <br />a <br />m <br />U) <br />U) <br />PE <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Codes <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />