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' WELIJPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED f � JOB ADDRESS CITY/ZIP m -- D v CROSS STREET APN_ PARCEL SIZE LAND USE APPLICATION# m rn OWNER NAME PHONE OWNER ADDRESS CITY/STATE/ZIP_ _ CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE i C-57 1 1 C-61 I D-09 1 1 Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township Range Section INTENDED USE 1 Domestic/Private r Irrigation/Agricultural i_' Industrial 1 i Water Quality Monitoring 1 Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 1 I New Well 1 Replacement Well - Well Alteration/Modification 1 Other I Monitoring Well(s) #of wells 1 1 Soil Boring(s) #of borings 1 Geotechnical #of borings I Out-Of-Service Well 1 1 Out-Of-Service Well Renewal I I Cross-Connection Repair 1 New Pump Pump Replacement Pump Repair -1 Raise Well Casing WELL CONSTRUCTION Drilling Method -' Mud Rotary 1 1 Air Rotary Auger I 1 Cable Tool 1 1 Push Point 1 Other Proposed Well Depth ft Excavation in diameter 1 Open Bottom I Gravel Pack/Gravel Size in diameter i 1 Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched I 1 Steel i Plastic 1 Stainless Steel I i Other Grout Seal Depth ft 1 Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water Bentonite(20%solids) 1 Other Grout Placement Method i i Pumped 1 1 Free Fall Other I, Retardant/Accelerator(name) PEDESTAL Installed By J Driller Pump Contractor Other Concrete Pedestal 1Dimensions:Width It Length It Thick in 1- Christy Box 1 Stove Pipe PUMP 1 Submersible, Turbine I Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 SIGNED TITLE DATE t IN I-T- —t-ril EHI DEPARTMENT USE ONLY Application Accepted By Date Area _ Employee ID# Grout Inspection By Date_ ❑ SPECIAL Well Permit Pump Inspection By _ _ _ _ Date_ ❑ WAIVER Received Soil Boring Inspection By Date_ _. — Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Permit/ Codes Info By Cash Remitted Date Service Request If Invoice# Well ID# EHD 43-06 WELL/PUMP PERMIT 4/30/12