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WELL/PU11IP PIERMIT R✓ i SAN JO"jOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS CROSS STREET OWNER NAME OWIVIACTOR ADDRESS = CO CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE C-57 CALL 209 953-7697 FOR INSPECTIONS EXPI1411=5 l YEAR FROM DATE ISSUEU _ i i Monitoring Well(s) # of wells I Soil Boring(s) # of CITY/ZIP j L %j / �" v ApN C/ PARCEL SIZE LAND USE APPLICATION # t�J\ VV\. L _ CITY/STATE/ZIP PHONE I Mud Rotary L, Air Rotary Auger I Cable Tool i i Push Point i Other 'v Proposed Well PHONE �7�I —9 l Conductor Casing in diameter / Conductor Casing Depth in Thickness/Gauge/ASTM Sched i Steel CITY/STATE/ZIP { Ci /C-- < �LTHb Grout Seal PHONE 1 D-09 Other CITY/STATE/ZIP NUMBER.�99rvl__) EXPIRATION DATE GFnGRAPHICAL INFORMATION: Coordinates X Y Township Range Section NTENDED USE I Domestic/Private Irrigation/Agricultural ! 1 Industrial Water Quality Monitoring Soil Sampling/Characterization i Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK iNewWell Replacement Well Well Alteration/Modification Other he ash i i Monitoring Well(s) # of wells I Soil Boring(s) # of borings i Geotechnical # of borings Permit/ Service Request # i Out -Of -Service Well n Out -Of -Service Well Renewal i Cross -Connection Repair New Pump >ePumpReplacement Pump Repair Raise Well Casin WELL CONSTRUCTION Drilling Method I Mud Rotary L, Air Rotary Auger I Cable Tool i i Push Point i Other 'v Proposed Well Depth ft Excavation in diameter Open Bottom I Gravel Pack/Gravel Size In diameter l Conductor Casing in diameter / Conductor Casing Depth in Thickness/Gauge/ASTM Sched i Steel ft %✓O i i Plastic Stainless Ste F�P/ Well CasingDiameter �LTHb Grout Seal Depth ft i Neat Cement (94 lb bag/5-10 gal water) i Sand Cement water ~ Ibcr- Bentonite (20% solids) Other Tb GroutPlacement Method :_i Pumped I i Free Fall I I Other i Retardant / Accelerator (name) PEDESTAL Installed By Driller Pump Contractor r. Other Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe PUMP i Submersible Turbine I i Other HP Pump Set r 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 CALIFO A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH LL WORKERS C TION LAWS. INIMU 4 HO D CE NOTICE REQUIRED FOR I CTIONS - PLEASE CALL (209) 953- 97 SIGNED �- TITLE _ DATE P ,TP."ENT U E ONLY Application Accepted By �`��'- Date Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS Area Employee ID#� ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft rn m D v v m m cn PE Codes Sc Info Received B he ash Amount Remitted ate Permit/ Service Request # Invoice # Well ID# EHD 43-06 WELL /PUMP PERMIT 4/30/12