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c <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1865 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL <br />(ZU9) 953-7697 FOR INSPECTIONS <br />EAR FKUA t 15bU <br />CJC I TUM tU <br />JOB ADDRESS <br />� <br />e_ P e_ <br />��` l oukI PN <br />CITY/ZIP I� <br />` <br />�CI'IKt0 <br />1_Jh O <br />Invoice # <br />CROSS STREET , <br />�G'�/}��,�C\� AP_N <br />VW ? �C) i _� PARCEL SIZE I LAND USE APPLICATION # <br />OWNER NAME <br />{} 8yA <br />�fJ�( ) j13 I <br />PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />LOS <br />CONTRACTOR <br />tIJQl\ A_ \CUIXJ0y_) AJ�JOCtiC� <br />C <br />PHONE <br />CONTRACTOR ADDRESS mCwsffiG1 iaAq <br />CITY/STATE/ZIP <br />t�luL L`Z QST lO <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE vAC-57 C-61 D-09 Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER (_0 (UC1G{'( EXPIRATION DATE S L 3_k <br />GEOGRAPHICAL INFORMATION: Coordinates X �I.`Z l75 Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ✓Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water bystem Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings OGeotechnical S # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth 50 -1 S ft Excavation ((l „ 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft /V`�I.eat Cement (94 /b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other -r M ' Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine 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 />MINIMUM 24/HOt-y/ UR AD�CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ,J TITLE F�V,:, 1 I DATE P,,--317 /'q <br />EP �RTMENT U E NLY <br />Application Accepted By Date ,; b <br />Grout Inspection Date <br />Pump Inspection By Date <br />Soil Boring Inspection ByDate !� l <br />COMMENTS <br />,r <br />4_�� <br />Area mployee ID <br />SPECIAL II Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Check#/ <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 />