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WELUPUMP PERMIT <br /> CAN JV.A,IUIN 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 /> to <br /> I, <br /> JOB ADDRESS �� W� I �• CITY/ZIP CS m <br /> D <br /> CROSS STREET44AAPN It ' �� PARCEL SIZE tJ / LAND USE APPLICATION# m <br /> rn <br /> OWNER NAME C>A PHONE <br /> OWNER ADDRESS l V O CITY/STATE/ZIP <br /> _rACONTRACTOR z PHONE (M <br /> CONTRACTOR ADDRESS �� v� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 I C-61 I D-09 I Other NUMBER 3 CUl <br /> 0 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE i Domestic/Private ')(Irrigation/Agricultural . 1 Industrial i Water Quality Monitoring I Soil Sampling/Characterization <br /> i Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK i I New Well 1 1 Replacement Well I i Well Alteration/Modification i I Other <br /> o 0 <br /> Monitoring Well(s) #of wells ! 1 Soil Boring #of borings s) 1 Geotechnical �Eov <br /> ARWCIVT <br /> 1 Out-Of-Service Well I Out-Of-Service Well Renewal i I Cross-Connection Repair <br /> New Pump I 1 Pump Replacement 1 Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION O18 <br /> Drilling Method I_ Mud Rotary I I Air Rotary 1 1 Auger .I Cable Tool I Push Point i l Other SAN JO <br /> CIVVProposed Well Depth ft Excavation in diameter i Open Bottom 1-1 Gravel Pack/Gravel%-A iRON"M�kgr�'Ea ter <br /> i Conductor Casing in diameter / Conductor Casing Depth ft "jTMENT <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 mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped !I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box I. Stove Pipe <br /> PUMP Submersible Turbine I 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 C RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C SATI LAWS. <br /> INIMUM 2 OUR ADU C OTICE REQUIRED FOOOOPECTIONS- PLEASE CALL(209)953-769 <br /> SIGNED TITLE DATE Q <br /> EP TMENWUSE NLYApplication Accepted By Date Area Employee ID# _— / <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By 4fMN ISVJ� {���11�s� Date lD XZVI `'� n WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount Permit/ <br /> Codes Info B s Remitted Date ervice Re uest# Invoice# Well ID# <br /> (� 4� 31Y S�Zftou3 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />