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S <br />WELUPUMP PERMIT <br />SAN JOAQUIN 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 ADDRESS <br />CONTRACTOR ADDRESS e'_C/ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE! C-57 I C-61 <br />CALL (209) 953-7691 FOR INSPECTION5 <br />CITY/ZIP <br />APN / /li 7 " 1� ` PARCEL SIZE <br />n D-09 ❑ Other <br />NUMBER <br />CITY/STATE/ZIP <br />CAII-Ir1C.7 1 i CAn rnvrvivm i r- oovw <br />^— - - <br />USE APPLICATION <br />�#_ <br />NE <br />PHONE :ill Y! I�J1 <br />JO'��L%Il <br />CITY/STATE/ZIP i T ms <br />PHONE <br />CkTY/STATE21P <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural N Industrial i.7 Water Quality Monitoring U Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: Water System Name sct game or Phone umber <br />TYPE OF WORK ❑ New Well [l Replacement Well ❑ Well Alteration/Modification ❑ Other <br />s of borin <br />C] Monitoring Well(s) # of wells ❑ b of borin s <br />Soil eoring(s) 9 ❑Geotechnical —PA s <br />D Out -Of -Service Well Ll Out -Of -Service Well Renewal [I Cross -Connection Repair p �-47 <br />F1 New Pum Pum Replacement U Pum Repair ❑ Raise Well Casing°����� <br />WELL CONSTRUCTION C <br />Drilling Method U Mud Rotary 11 Air Rotary F', Auger Li Cable Tool U Push Point 11 Other JUL 0 6 ala <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I-1 Gravel Pack/Grav(§*i l In diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft HENT UNTy <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic C Stainless Steel ❑ BIQPPARTMPNIr <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />LI Bentonite (20% solids) 11 Other <br />Grout Placement Method U Pumped .1 Free Fall Other U Retardant /Accelerator (name) <br />PEDESTAL Installed By 1-1 Driller C] Pump Contractor ❑ Other <br />Concrete Pedestal ;­ Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Y�Submersible11 Turbine 11 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 CDMPENSATION LAWS. <br />SIGNED <br />EP RTMENT <br />C � <br />U E LY <br />Application Accepted By <br />Date Ile <br />Grout Inspection By <br />Date <br />Pump Inspection By _ >� <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area lEmployee I D# "17 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />_N <br />A <br />v <br />v <br />m <br />N <br />N <br />PE <br />Sc <br />Info <br />ReceivedChec <br />B <br />ash <br />Amount <br />Remitted <br />Date <br />Permit/Codes <br />Service Request # <br />Invoice # <br />Well ID# <br />(�� <br />l 7 7 <br />VO S <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />