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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 />NUN-KEFUNDABLE PERMIT <br />(:ALL VU9) 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS b I v i <br />� 7 <br />ct//-AF'IKtb <br />CITY/ZIP 71UG <br />Z f 5 z I <br />r�A <br />CROSS STREET I APN 1 C L/ b <br />- U / PARCEL SIZE tic (13 <br />LAND USE APPLICATION # <br />OWNER NAME A <br />G r d <br />/- C <br />PHONE <br />OWNER ADDRESS <br />����)u�, <br />CITY/STATE/ZIP <br />-yZ <br />CONTRACTOR /VQ <br />f P(L <br />� <br />PHONE-741 <br />7-! <br />4 :7 --�3/ <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />� <br />L'Y'7 ZLo <br />IV14 <br />SUBCONTRACTOR <br />PHONE <br />/,/l4 <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 C-61 <br />D-09 Other <br />NUMBER _ "I 6G 1 <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring XSoil 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 Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical 2 # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing p� <br />Drilling Method Mud Rotary Air Rotary >(Auger Cable Tool Push Point Other rVECpie <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Sizein <br />Conductor Casing in diameter / Conductor Casing Depth ft ' 120 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel a�*ef119 <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand CementE ly ater <br />UIVN <br />Bentonite (20% solids) XOther b N �� n ; / 2 h S STN pMEN(Tq <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) TA1 <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 THA 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�AWS. <br />A& EPARTMENT USE ONLY <br />Application Accepted By2� Date <br />Grout Inspection By r Date <br />Pump Inspection By Date <br />Soil Boring IInsffpecti By Date J <br />COMMENTS („/I Zj� a r (i 'al -, e -n 's,19a YlA . + <br />T <br />1 <br />Area ) L/q L Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Const,�cted Well Depth <br />S L v�l s�'a d- pa -D e rpd f , <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />CChecAW <br />Uash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />dIP- <br />zzZIf <br />3 °I <br />t� I► ( <br />����)u�, <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />