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-r <br />Sian <br />WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS It LA&I <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS G <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE �! C-57 f] C-61 ] D-09 <br />❑ Other <br />QTY/STATE/ZIP- / L'` I <br />NUMBER EXPIRATION DATE <br />GEOGRAPHICAL IN ORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private n Irrigation/Agricultural U Industrial D Water Quality Monitoring U Soil Sampling/Characterization <br />[] Public Water System <br />If different from Owner: Water System Name-------- Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings a Geotechnical # of borings <br />❑ Out -Of -Service II IJ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I I New Pump 4PumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary I Auger ❑ Cable Tool L] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 'J Steel Ll Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth It I] Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) U Other <br />Grout Placement Method I_] Pumped :I Free Fall F, Other C' Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />r, Concrete Pedestal CDimensions: Width ft Length ft Thick in ❑ Christy Box P Stove Pine <br />PUMP (Submersible[; Turbine 1; Other HPC_ Pump Set jL&Z ft Standing Water Level(4 1-1 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 />UM 24HO HOWDV NN�O,� CE REQUIRED FOR INSP T DNS - PLEASE CALL (209))953/-7 97 1�] <br />SIGNED�VAA" %�i'Y xP TITLE _ __ DATE t"Y/tl` & <br />1_ F_-._LLED I I- <br />m <br />D <br />O <br />D <br />m <br />m <br />y <br />y <br />Application Accepted By <br />D PARTMENT USE ONLY <br />Date �J <br />Area Employee ID#Uti <br />LL <br />Grout Inspection By <br />Date <br />❑ SPECIAL Well Permit <br />Invoice # <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />_ Date <br />Constructed Well Depth <br />ft <br />COMMENTS <br />wpoo3�w-5L <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Che # <br />---C—ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />12— <br />D .`) <br />wpoo3�w-5L <br />EHD 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />