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GUS %GyIV E L UP U M P PERMIT Q '/ <br />SAN JOAO COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL ZUy UOJ-/by/ FUH INSF'tG I IUNS r_Ar1ntr0 1 / CMn rnvrvi vAir- <br />JOB <br />ir- <br />VA <br />JOB ADDRESS CITY/ZIP <br />i2aj:? <br />CROSS STREET APN ��- PARCEL SIZE U. LAND USEE�APPLICATION # <br />-�V J _ PHONED <br />l t� u <br />OWNER NAME � /� <br />OWNER ADDRESS CITY/STATE/ZIPa%k* /[ t q f <br />CONTRACTOR PHONE aq�! ' <br />CONTRACTOR ADDRESS 4 20 111 eo- CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACT R ADDRESS / CI /STATE/ZIP / <br />LICENSE C-57 1 C-61 1 D-09 P Other NUMBER EXPIRATION DATE <br />GFor;RAPw -Ai ImrnRMATinm: r:nnrcfinatAR X Y Townshin Rana@ Section <br />NTENDED USE Domestic/Private n Irrigation/Agricultural ❑ Industrial [.i Water Quality Monitoring U Soil Sampling/Characterization <br />H Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK n New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well U Out -Of -Service Well Renewal IJ Cross -Connection Repair <br />I ; New Pump )(Pump Replacement ❑ Pump Repair FI Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary ❑ Air Rotary Cl Auger ❑ Cable Tool U 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 'J Steel LiPlastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth It C', Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />1 Bentonite (20% solids) : I Other <br />Grout Placement Method [ 1 Pumped is=1 Free Fall F Other H Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller '7 Pump Contractor ❑ Other <br />Concrete Pedestal ;:'Dimensions: Width ft Length ft Thick in U Christy Box rl Stove Pipe <br />PUMP Submersible Ci Turbine 1 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 />WORKERSCOMPEN TION LAWS. <br />MIHO ANCE NOTICE REQUIRED FOR I PECTIONS -PLEASE CALL (209) 9521-76y <br />SIGNED TITLE /`Z'/�+�^ DATE OW 5 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARTMENT USE ONLY <br />Date <br />Date <br />a Date Z`?i <br />Date <br />Area gL ) 0 I Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />v <br />v <br />M <br />m <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/Invoice <br />Service Request # <br /># <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />