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WELL/PUMP PERMIT f ✓ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS 0, _. <br />CROSS STREET2- NA <br />OWNER NAME V <br />OWNER ADDRESS. <br />i17NA IJ <br />CONTRACTOR V <br />//�' r <br />CONTRACTOR ADDRESS _ I <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE �57 .j C-61 <br />CALL 209 953-7697 FOR INSPECTIONS t Ylhta t r tAH I-HUno uH I t roaUcu <br />CITY/ZIP <br />APN l i,S V PARCEL SIZE , / LAND USE PPLICATION #_ <br />VI PHONE _ 2_ --._MD - — <br />/J��/)��/) �C��J �D�LNj�w� <br />V. CITY/STATE/ZIP /y� c�L701 I+'� W''%LP' _ PHONE <br />I`L0,111 CITY/STATE/ZIP� i / <br />/ PHONE f <br />I D-09 P Other <br />NUMBER <br />Lo EXPIRATION DATE Jt� <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section__ <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural L1 Industrial Li Water Quality Monitoring LI Soil Sampling/Characterization <br />I 1 Public Water System <br />If different from Owner: Water Name Cont actName or Phone -Number <br />TYPE OF WORK C] New Well I i Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) _ # of wells L Soil Boring(s) Mot borings Geotechnical —M bvrmgs <br />❑ Out -Of -Service W II [i Out -Of -Service Well Renewal LI Cross -Connection Repair <br />C' New Pump Pump Replacement Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I I Mud Rotary Lj Air Rotary C Auger L1 Cable Tool I_! Push Point I Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom i l Gravel Pack/Gravel Size in diameter <br />LI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel 11 Plastic Stainless Steel -,I Other _. <br />Grout Seal Depth ft P Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) r 1 Other <br />Grout Placement Method i 1 Pumped I Free Fall I- Other I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller- Pump Contractor _ Other <br />Concrete Pedestal Dimensions: Width It Length ft Thick in l Christy Box h Stove Pipe <br />PUMP Submersible I1 Turbine f ; Other HP Pump Set ft Standing Water Level It <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 />MI HOUR ADVANCE NOTICE REQUIRED F07PS - LEASE CALL (209) 95 -76 7 <br />SIGNED TITLE L4 DATE <br />DEPARTMENT/USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By _ 3 Date 0 <br />Soil Boring Inspection By Date <br />COMMENTS <br />i <br />Area Employee ID# <br />IJ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth _. ft <br />X <br />-i <br />D <br />O <br />0 <br />m <br />m <br />N <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />%41 <br />cw <br />�� <br />►fig <br />3 � <br />� � �i <br />WPc�;���� <br />END 43-06 WELL/PUMP PERMIT <br />4/30/12 <br />