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5UA-, t -D-0 -t7 -)�P-\ , L. <br />WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT (:ALL <br />JOB ADDRESS <br />CROSS STREET I + <br />OWNER NAME <br />C <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE I�C-57 C-61 ! I D-09 I I Other <br />11b3-/byVI FOR INQSPECTIONS tXl'IHtS 1 YEAR FROM LATE ISSUED <br />Z I�/ ` CITY/ZIPL (r"�� Cy CF% 2,� ll' <br />P/t1RCEL SIZE LAND USE APPLICATION # <br />PHONE <br />C r- <br />CITY/STATE/ZIP <br />PHON�p�✓yL/ <br />CITY/STATE/ZIP / L�'�+�, <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER i?q � Lj0 EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private I Irrigation/Agricultural I Industrial I Water Quality Monitoring ! 1 Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK n New Well I I Replacement Well I I Well Alteration/Modification I I Other <br />I I Monitoring Well(s) # of wells I Soil Boring(s) # of borings I I Geotechnical # of borings <br />1 Out -Of -Service Well I Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />ew Pump I I Pump Replacement I I Pump Repair i Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary I I Air Rotary Auger I Cable Tool I 1 Push Point 1 1 Other <br />Proposed Well Depth it Excavation in diameter Open Bottom 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 Plastic I I Stainless Steel Other <br />Grout Seal Depth ft 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 Pumped i Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor 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 LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI M 24 HOU AD NC NOTICE REQUIRED FOR INSIPEC IONS -PLEASE CALL (209) :53-2197 <br />�` �� , j�� y r DATE <br />SIGNED ��� b�"' V'�y1 TITLE <br />DEPARTMENT USE NLY <br />t <br />Application Accepted B Date Area Employee ID#v► <br />Grout Inspection By A Date / ❑ PECIA Well Permit <br />n <br />Pump Inspection By ' Date b I' IJ ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <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 />(� <br />-3 <br />` <br />20 <br />SKOO-7(66-7 <br />vvPoa 22c�3 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />