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WELUPUMP PERMIT <br />I? SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NOtVREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />QMJOB ADDRESS `� 1 �1 II! ?) 0 ) CITY/ZIP <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />AP C o1� �'� PARCEL SIZE �' LAND USE APPLICATIIO� N # <br />CITY/STATE/ZIP(—,A U <br />LICENSE-- I(7 C-57 ❑ C-61 ❑ D-09 11 Other <br />GEOGRAPHICAL INFORMATION: Coordinates X <br />Y <br />CITY/STATE/ZIP <br />PHONE <br />C TY/STATE/ZIP <br />NUMBERq2ff/-(a EXPIRATION <br />Township Range Section <br />INTENDED USE XDomestic/Private F1 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />LI -Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out-Of-ServiceI ❑ ut-Of-Service Well Renewal ElCross-Connection Repair <br />F.1New Pump X, mp Replace ent )(Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method [ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ 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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />C Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />L Concrete Pedestal I_iDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 1 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 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS OMPENSATION LAWS. <br />N UM H A VANC OTICE REQUIRED F R INSPE TIONS - PLEASE CALL (209 9 3-707 <br />SIGNED TITLE DATE <br />Area q1 Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Date t ti C <br />Grout Inspection By <br />Date <br />Pump InspectieW, <br />Date I <br />Well ID# <br />- <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area q1 Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />B <br />Check#/ <br />Cas <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43.06 WELL/PUMP PERMIT <br />4/30/12 <br />