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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 />NON-REFUNDABLE PERMIT C LL 209 953-'1 <br />7/11697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS Q CITY/ZIP Zy� <br />CROSS STREET JAPN PARCEL SIZI?�AND USE APPLICATION # <br />OWNER NAME P�H(OON�E <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR I I �'-HOONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR / PHONE <br />SUBCONTRACTOR ADDRESS CITY/STA P <br />LICENSE / 1.-57 C-61 D-09 V// Vthef NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: COordln es • Y ,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 bystern Name Loontad Name or one Number <br />TYPE OF WORK New Well Replacement Well - Well Alteration/Modification Other <br />Monitoring Well(s) # of wells F Soil Boring(s) # of borings Geotechnical # of borings <br />t -Of -Service Well,[QI� t -Of -Service Well Renewal Cross -Connection Repair <br />n Pump Pump Replacement ;/YUmD Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Dept ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 /b bagl5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedes I Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Aurbine Other HP Pump Set_' ft Standing Water Level _ ft <br />I HEREBY Y THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUI OUN RDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURREAT AND AC LVE—HIITHiTHE-6QLIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />MINfj 24 7TDVAICE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE DATE 5.2.847 <br />ur <br />D <br />a <br />N <br />U <br />E.fp R T M E N T USE qNLY <br />Application Accepted By Date Area c/'I Com/ Employee ID# �rQ <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection ByDate Q WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check <br />Codes Info By s <br />Amount <br />Remitted <br />Date <br />Pe rmiU Invoice # Well ID# <br />!� <br />jServiceReequueest#1 <br />A,O <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />