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WELUPUiVii-) �cRMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT _ CALL <br />JOB ADDRESS (� /✓ I I 1 l�Ir�ls �'\ <br />CROSS STREET APN <br />OWNER NAME C, Mr) e <br />953-7697 FOR INSPECTIONS <br />_�9f7. v <br />OWNER ADDRESS I� pp <br />CONTRACTOR 1 1 1 xt— <br />'fiVICONTRACTOR ADDRESS "V t A\ Q, <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 E C-61 [ I D-09 1! Other <br />EXPIHES 1 YEAR FROM DATE ISSUED r <br />_ CITY/ZIP 1 [ 2 <br />CEL SIZE -LAND USE APPLICATION It <br />IR , PHONE <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE ZIP `J 2L ' , k- , Z <br />CITY/STA�T/E/ZIP _ <br />NUMBER ,til^ I'7�y <br />PHONE <br />EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE X Domestic/Private Irrigation/Agricultural 1 Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name------- (�&Nlact Name or Phone Number <br />TYPE OF WORK New Well I Replacement Well ! I Well Alteration/Modification Other <br />Monitoring Well(s) # of wells I Soil Boring(s) # of borings Geotechnical #°^ <br />Out -Of -Service Well Out -Of -Service Well Renewal i I Cross -Connection Repair C����`D <br />I New Pump 'IV Pump Replacement 1 Pump Repair I I Raise Well Casing ADD y _ <br />WELL CONSTRUCTION . <br />' r ( C018 <br />Drilling Method I Mud Rotary Air Rotary Auger Cable Tool Push Point Other '%%--JOAQ,,p <br />Proposed Well Depth ft Excavation in diameter ! Open Bottom Gravel Pack/GraV�tl tj. Meter <br />Conductor Casing in diameter / Conductor Casing Depth ft ARTMENT <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ' i Steel I i Plastic I Stainless Steel i Other <br />Grout Seal Depth ft I Neat Cement (94 Ib bag/5-10 gal water) I I Sand Cement _. sack mix/7 gal water <br />I I Bentonite (20% solids) 1 Other <br />Grout Placement Method !_ 1 Pumped I Free Fall i Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By I Driller I 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_L 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 COMPLU.7697 <br />L <br />WORKERS COMPENSATION LAWS. <br />INIMU 24 HOUR ADVAN OTICE REQUIRED F�PECTIONS - PLEASE CALL (209) 9SIGNED TITLE I / DATE <br />DE ARTMENVUj E N L Y <br />Application Accepted By ' Date <br />Grout Inspection By Date <br />Pump Inspection By Date Al 1 <br />Area -A?qEmployee I D# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />T <br />1 <br />D <br />v <br />v <br />m <br />N <br />0 <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Che Amount <br />ash Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />deg- <br />S/ 7,�� <br />cv OO&I5 <br />EHD 43.06 WELL /PUMP PERMIT <br />4/30/12 <br />