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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 --M Mr',- -4 n 0ICCI ICO NON-REFUNDABLE PERMIT JOB ADDRESS LAU CROSS STREET OWNER NAME �- OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR ADDRESS CALL (; UOJ-/Ott / FUFI1NbFt'_IIVN0 / U U PARCEL SIZE 7yli�` y ' 1 t7� USE JONE i 1111-11141/ PHONEiI A LICENSE & C-57 r1 C-61 1 D-09 [1 Other NUMBE EXPIRATION DATE GFOGRAPH .AL INFORMATION' Coordinates X Y TOWnshio Range Section I or INTENDED USE Domestic/Private C7 Irrigation/Agricultural ❑ Industrial L; Water Quality Monitoring ❑ Soil Sampling/Characterization l Public Water System If different from Owner: Water System Name ontact ame or Phone umber TYPE OF WORK ❑ New Well P Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) If of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service ell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger U Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation in diameter �_] Open Bottom h Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water 11 Bentonite (20% solids) '.1 Other Grout Placement Method U Pumped _� Free Fall Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other _ Concrete Pedestal :: Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP SubmersibleU Turbine I; Other HP Pump Set It Standing Water Level ft I HEREBY CER FY 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENS ION LAWS. NIMUM H D CE NOTICE REQUIRED F R INSPECTIONS - PLEASE CALL (209) 9, 3- h I�-HDIN SIGNED TITLEY/1A MI— DATE Area _q/Employee ID# d ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft a v v m m N PE Codes EP RTMENT U E ONLY E, Application Accepted By Date// 2, /P Grout Inspection By Date Pump Inspection By 4 Date Soil Boring Inspection By Date COMMENTS Area _q/Employee ID# d ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft a v v m m N PE Codes SC Info Received B Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 7 2« v sb 5 EHD 43-06 WELL/PUMP PERMIT 4/30/12