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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 />NUN-KEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP .1,C-:)4 <br />�p <br />CROSS STREET -o. In )C=r—\t� �y APN ��(jJC��(� Q PARCEL SIZE �I 1.� LAND USE APPLICATION # <br />�,� <br />OWNER NAME (/vV t/iJ [ �C— (/P r�PHONE <br />OWNER ADDRESS/ 7 —7�JCe ( 1 ( I(jU CITY/STATE/ZIP —61C —7 S-00-4) <br />CONTRACTOR �' y� 1 f1, (��Q•���```�-�� PHONE <br />CONTRACTOR ADDRESS v 1 h_`4411- AO (Q(AW CITY/STATE/ZIP �C� (. C 3 q S2 -L10 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE L --C-57 C-61 D-09 Other NUMBER (PCQC lC EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X ,�%., r�75 (�L4 Y —u-�. ?---j 2,2 Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring V Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Out -Of -Service Well <br />Well Alteration/Modification Other <br />Soil Boring(s)# of borings <br />� Geotechnical � <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />New rump rump Keplacement rump Kepair Kaise well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary 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 Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb 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 'iL 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 />MINIMUM24 O/U!R AA <br />E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 1 `Z/ TITLE All DATE �� I <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />y <br />N <br />t . EP R T M E N T U E O LY <br />Application Accepted By Date V ✓b Area i 4ALj I PIP Rv Employee ID#Ay:t� <br />Grout Inspection By Date �I �S SPECIAL iVell Permit <br />Pump Inspection By Date _ WAIVER Received <br />Soil Boring Inspection B bI Date i Constructed Well Depth ft <br />COMMENTS <br />PE SC <br />Codes Info <br />Received <br />By <br />Che <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br /># <br />Invoice # <br />Well ID# <br />223oCD <br />aa <br />nService <br />\�Request <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />