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WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS CArlrt W I I tAn rnum vm i r- raavw <br />6 <br />JOB ADDRESS % CITY/Zip '- <br />CROSS STREET APN �" —g PARCEL SIZE " fC• Z 7LAND USE APPLICATION # <br />.. A — ^ - --ryl-%_1/.c�- i/ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR_ <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 n C-61-57 `7 C-61 <br />F) D-09 C7 Other <br />NUMBER <br />CITY/STATE/ZIP \� <br />LJ PHONE (J\1!'/ �mEf7 I—' <br />CITY/STATE/ZIP <br />PHONE <br />CI Y/STATE2IP <br />TUOUP EXPIRATION DATE�.r !9 <br />aEOGRAPHICAL INFORMATION: L;oorainates x x t ownsmp riange aeusion <br />Of <br />NTENDED USE Domestic/Private L7 Irrigation/Agricultural ❑ Industrial L; Water Quality Monitoring 0 Soil Sampling/Characterization <br />t Public Water System <br />If different from Owner: Water System Name ontact ame or Phone Number <br />TYPE OF WORK 0 New Well L1 Replacement Well ❑ Well Alteration/Modification CI Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) If of borings , Geotechnical It of borings <br />0 Out -Of -Service II LI Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />F New Pump it Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 0 Mud Rotary Li Air Rotary ❑ Auger 0 Cable Tool Cl Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter -1 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ii Steel ❑ Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth ft C' Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) t I Other <br />Grout Placement Method t 1 Pumped Ll Free Fall F Other a Retardant / Accelerator (name) <br />PEDESTAL Installed By 11 Driller ,1 Pump Contractor 0 Other <br />Concrete Pedestal CDimensions: Width ft Length ft Thick in Christy Box n Stove Pipe <br />If <br />PUMP Submersible.'! Turbine I' 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 COMPEN ON LAWS. <br />IMUM O ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE - - <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />.Date 7,1 ZJ <br />Date <br />Date1 <br />Date <br />Area1 Employee ID#�\ <br />11 SPE 'IAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />P", <br />v <br />v <br />m <br />m <br />in <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />(ChecW <br />'-Msh <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />ir3� <br />a� <br />i 3 <br />�-1 <br />���-i <br />Po ,��s�1 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />