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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 />..r._n a \/IlwTc rCM <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME V <br />C <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />CALL(2U9) 9b3 -/by/ FUH IN5I tGIIUNJ--- <br />wnkr /) ,j( 6 y K O 4 0 <br />CITY/ZIP c� 1 1� lt r 1 1T <br />PAnrF1 S17F I • U ! LAND USE APPLICATION # <br />ADDRESS <br />LICENSE ZC-57 '1 C-61 [1 D-09 P Other <br />NUMBER <br />P <br />PHONE <br />EXPIRATION DA <br />3EOGRAPHICAL INFO NATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private Cl Irrigation/Agricultural U Industrial Ei Water Quality Monitoring Ll Soil Sampling/Characterization <br />11 Public Water System <br />If different from Owner: Water System Name fact ame or Phone umber <br />TYPE OF WORK n 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-Servic ell LI Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />P New Pump Od,Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary Ci Air Rotary n Auger ❑ Cable Tool U Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom L] Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel 11Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft [l Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />_I Bentonite (20% solids) '.1 Other <br />Grout Placement Method 1.1 Pumped :--1 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller :J Pump Contractor ❑ Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in it Christy Box ❑ Stove Pipe <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 COMPENSATION LAWS. <br />MI =VANCE NOTICE REQUIIRREDD FORINSPECTIONS - PLEASE CALL (209) 9537697SIGNED / �iL�,�%% �� a ITLE G�G� r -- - - DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By/ Date 1y'� �— <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area CI Employee ID# Ah <br />0 SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />(Checic#/,Y <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />os <br />17 <br />END 43-06 <br />4/30/12 <br />WELL/PUMP PERMIT <br />