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opt Tnihal Sian 04-7 AV <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Y <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ✓C-57 <br />CALL <br />VbJ-/bU[ FOR INSPECTIONS <br />1 • Other NUM13ER <br />tAVIHt, I YEAH FROM DATE ISSUED <br />OMM"Al«/.IJI'/ A1�1 <br />• • <br />PHONE qi % <br />PHONE <br />PHONE <br />EXPIRATION DATE I 3 ) <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED USE -Domestic/Private i Irrigation/Agricultural n Industrial i- Water Quality Monitoring i Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK i New Well Replacement Well Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />New Pum ump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method i Mud Rotary Air Rotary i Auger Cable Tool Push Point i 1 Other <br />Proposed Well Depth ft Excavation in diameter ! Open Bottom IGravel 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 i Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement sack mix17 gal water <br />Bentonite (20% solids) 1 Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor i Other <br />Concrete Pedestal Dimensions: Width ft Length ft Thick in i Christy Box I Stove Pipe <br />PUMP Ubmersible ' Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIA1 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 COMPENSATION LAWS. <br />MI H UR VANCE NOTICE REQUIRED FOPJNSP�ECTIIOONS`-/PLEASE CALL (209) 953-77697 <br />SIGNED TITLE DATE, y���/ DATE I r •I <br />DEPARTMENT USE ONLY <br />Application Accepted BY Date _ b Area 0 t Employee ID# <br />Grout Inspection By Date C ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />m <br />n <br />0 <br />0 <br />m <br />m <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />ChecAmount <br />s h <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />_)7 ti� <br />W 0030° ub <br />EHD 43.06 WELL/PUMP PERMIT <br />4/30/12 <br />