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WELL/PUMP PERMIT lc5'vl <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />CALL (ZU9) 953-7697 FOR INSPECTIONS tAPIKtS 9 TEAR FROM DATE ISSUED <br />JOB ADDRESS <br />/ <br />'i '� <br />7 <br />CITY/ZIP 7 7 <br />CROSS STREET /� <br />Well ID# <br />APN <br />31ZE �L I C: LAND USE APPLICATION # <br />T <br />OWNER NAME <br />LP <br />PHONE / L�p <br />- moZc <br />pC <br />OWNERADDRESS <br />CITY/STATE/ZIP C.1 �CQIJV1M 0p L <br />CONTRACTOR <br />. <br />fcy'(Sen <br />PHONE <br />CONTRACTOR ADDRESS <br />GIOZ I YtdUSfC �C <br />kI 1 C5L <br />/` U <br />CITY/STATE/ZIPLOCA C. Cl C� S �- L 11 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ✓C-57 C-61 D-09 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER CIL' l LC' EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X 3-7 1+1(C Y —k L1 C3S L-�' Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ✓Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water ys em Wainhe Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification IOther <br />✓Soil Boring(s) . 1 • I _ # of borings Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />New Nump rump Keplacement rump Repair Kaise wen casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth Li& ft Excavation (v 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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Meat Cement (94 Ib bag/5-10 gal water) /� Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) 'fit Sy� <br />Grout Placement Method Pumped 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ////_TtJT _`i=�{y�� TITLE'7( DATE/ 7G/ C <br />VEP RTMENT USE ONLY <br />�- <br />40& <br />Application Accepted By Date <br />Grout Inspection By <br />Pump Inspection By ,�f <br />Soil Boring Inspection By 'M'1' <br />COMMENTS <br />Date <br />Date <br />Date 7 <br />-a <br />m <br />D <br />v <br />v <br />m <br />m <br />ur <br />Area 15- Employee lD#An/"r� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Chec <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />