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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 <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDREVU_o2 <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE \j"11-57 11 C-61 <br />CALL <br />KM <br />I� <br />i 1 D-09 [1 Other <br />9b;3 -/b9/ FOR INSPEGIIUN5 CArincii 1 1CAn rnum vmiv- ovw <br />CITY/ZIP ,.l R I 1 I C1� 3' <br />ARCEL SIZE -S LAND USE APPLICATION # <br />?f /t=� L nan I iL P� HONE Log rr�1 <br />CITY/STATE/ZIP V ��+�} !!�� `(��✓ <br />�PA <br />P]]H\\ONE�/�Y�IjJ��1 <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER UV I �k EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE l omestic/Private -- Irrigation/Agricultural ❑ Industrial Ci Water Quality Monitoring ❑ Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C7 New Well [1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I New Pump Y__pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Ll Mud Rotary [I 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 Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel Li Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 17 Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />-1 Bentonite (20% solids) [ I Other <br />Grout Placement Method [-7 Pumped ❑ Free Fall 7 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />Concrete Pedestal --Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP VAUI bmersibleCl Turbine 1; Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CER FY 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 />MINIMUM 24 HOU ADVANCE NOTICE REQUIRED FO IN�SpPECTIONS`- PLEASE CALL (209 53-17697 <br />SIGNED 6 W �' TITLEQ�L.�I_ aSS� U \ 1.t DATE I <br /><EPARTMENT USE NLY <br />Application Accepted By <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By YU-Date <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area Employee ID#& <br />11SPECI L Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Chec <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />