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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 />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I I I/ f} (��� I l CITYrZIP tu�bmC-y"I al 5 <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS ll <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ADDRESS <br />APN �! '�3O' l_ _PARCEL SIZE LAND USE APPLICATION #q In <br />A n n '�,/�� PHONE <br />V! PV L/!/X / CITY/STATE21P L Y <br />ATE/ZIP <br />LICENSE C-57 f ] C-61 [ 1 D-09 n Other NUMBER EXPIRATION DATE I ;2 <br />GEOGRAPH AL I ORMATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private n Irrigation/Agricultural I"J Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />[l Public Water System <br />If different from Owner: Water System Namet Name or Phone Number <br />TYPE OF WORK n New Well I I Replacement Well ❑ Well Alteration/Modification [I Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service ell ❑ Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />Cl New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel [IPlastic C Stainless Steel 0 Other <br />Grout Seal Depth ft ,-? Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />!.I Bentonite (20% solids) � 1 Other <br />Grout Placement Method i 1 Pumped ❑ Free Fall n Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By a Driller '7 Pump Contractor ❑ Other <br />Concrete Pedestal F Dimensions: Width ft Length ft Thick in 0 Christy Box n Stove Pipe <br />PUMP 1A Submersible[_I 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN$/TION LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS rJO �tU <br />RTM ENT USE PNL1 <br />Date :7 7iWI <br />Date <br />Date 1 <br />Date <br />Area--t/q4 Employee ID#VVXI(7 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed WellAepth ft <br />,rz <br />m <br />a <br />v <br />0 <br />m <br />m <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 />op <br />EHD 43.06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />