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WELUPUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE IJERM11 <br />4114 � <br />JOB ADDRhSS_ <br />CROSS STREET T TSI V J'r <br />OWNER NAMES { <br />OWNER ADDRESS W <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE l)(C-57 <br />GALL 1ZU'JI y5J-/69/ FOR INSPECTIONS tAF'lhtS 7 YEAR FROM UATE ISSUED <br />A <br />—(Otte V � ,e CITY/ZIP <br />AP , PARCEL SIZE r AND USE APPLICATION # <br />�� PHON <br />"CITY/STATE/ZIP <br />PHONE CSM <br />CITY/STATE/ZIP <br />PHONE <br />C-61 D-09 Other <br />3 <br />CITY/STATE/ZIP �� <br />NUMBER 3??v v CV V EXPIRATION DA <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE I Domestic/Private (Irrigation/Agricultural I Industrial Water Quality Monitoring I 1 Soil Sampling/Characterization <br />I Public WaterSystem <br />If different from Owner: Water System Name------- Co—ntact Name or Phone Number <br />TYPE OF WORK i , New Well _I Replacement Well I I Well Alteration/Modification I- Other <br />I i Monitoring Well(s) It of wells I Soil BoringN of borings s) I Geotechnical <br />I1 Out -Of -Service Well I i Out -Of -Service Well Renewal I I Cross -Connection Repair <br />_Aorings <br />New Pump I Pump Replacement ypump Repair I Raise Well Casing��(,' d/ <br />41 VP6Zj% <br />WELL CONSTRUCTION /firs <br />Drilling Method I Mud Rotary I I Air Rotary Auger i Cable Tool Push Point Other D <br />Proposed Well Depth ft Excavation in diameter Open Bottom I Gravel Pack/Gravel S' JO JOS A^ in tileter <br />Conductor Casing in diameter / Conductor Casing Depth ft /YFq(��TV/RO`iy"�NCOU <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel Plastic 1 Stainless Steel I OtheWMIT L <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/-PArwater <br />I 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 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 NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CQUIPE11SATtON LAWS. <br />II_ <br />Q�NOTICE REQUIRED TIS ECTIONS - PLEASE CALL (209) 953= <br />SIGNED �/TITLE &/TI <br />DATE ej <br />►�J//��►/�//�/y, DE ARTMENT U E UN LY <br />Application Accepted By /� Date <br />Grout Inspection By Date <br />Pump Inspection ByDate�O <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area_�V l� Employee ID# <br />LI SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />D <br />0 <br />v <br />m <br />m <br />rn <br />PE SC <br />Codes Info <br />Received <br />B <br />4ebeq&D <br />Cash <br />Amount <br />emitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />317TO <br />wP 0\n <br />EHD74 0 WELL /PUMP PERMIT <br />4/30/1212 ).6D T <br />C'If <br />