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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />A. Ir. ern <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS I I � <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS L <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 57 ] C-61 I D-09 P Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />r' <br />CALL 209 953-7697 FOR INSPECTIUN5 <br />I_ArInL; 1 1 amn rvn . +......- <br />Received <br />B <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Request # <br />C.1117.1111 <br />Well ID# <br />1 <br />lEllPov <br />s� <br />ABU— PARCEL SIZE4 -A kLAND <br />USE APPLICATION <br /># <br />/� <br />11 Z <br />PHONE <br />A <br />���/ <br />/ C, ITY/STATE/ZIP_4 <br />kj)n�° <br />r <br />PHONE <br />��> � <br />���y� <br />CITY/STATE/ZIP <br />►� <br />'+^ <br />PHONE �A <br />1 / / t <br />NUMBER ttL�5 nw W EXPIRATION DATE T/T <br />Y TownshiD Rancie Section <br />INTENDED USE N <br />omestic/Private C -� Irrigation/Agricultural ❑ Industrial I:] Water Quality Monitoring ❑ Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water ystem Name ontact ame or Phone Number <br />TYPE OF WORK Fi New Well Ll Replacement Well ❑ Well Alteration/Modification ❑ Other <br />U 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 />[1 New Pum /Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary ❑ Air Rotary i:, Auger ❑ Cable Tool U Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 'J Steel 11 Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft C] Neat Cement (94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack miad7 gal water <br />1_[ Bentonite (20% solids) . I Other <br />Grout Placement Method [ ] Pumped :_I Free Fall F Other [' Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />Concrete Pedestal I -Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible I_ Turbine 1: Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIVY 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 />WORKER$ -COMPENSATION LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARTMENT//U /E NL1 <br />—� Date `[ ` <br />Date <br />Date,1 <br />Date <br />Area LOqq Employee ID# <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />to <br />n <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Check#/ Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />1 <br />lEllPov <br />s� <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30112 <br />