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WELUPUMP PERMIT <br /> SAN JOAQUIN 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 /> JOB ADDRESS ` v �J v 7 L J CITY/ZIP c, / � j 212- n <br /> � O <br /> CROSS STREET PM J L I!� APN PARCEL SIZE LAND USE APPLICATION# <br /> Cn <br /> OWNER NAME PHONE ` } to <br /> JJ <br /> OWNER ADDRESS X CITY/STATE/ZIP <br /> CONTRACTOR S.S� PHONE �- <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 3 <br /> SUBCONTRACTOR � 1 �L�'�t/ PHONE v <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /' <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE C <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Dom estic/Privat Irrigation/Agricultural Industrial Water Quality Monitoring �] Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ystem Name --------(7ontact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well Well Alteration/Modification I Other <br /> L 1 Monitoring Well(s) #of wells i Soil Boring(s) #of borings i Geotechnical n of borings <br /> Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> 'W"'NeW Pum _ Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodK.Mud tary - Air Rotary i Auger I Cable Tool i i Push Point i i Other <br /> Proposed Well Depth c7o 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 ET— in Thickness/Gauge/ASTM Sched Steel 4<Plastic StainI Steel Other <br /> Grout Seal Depth L ft Neat Cement(94 lb bag/5-10 gal water) ,,Sand Cement sack mix/7 gal water <br /> i I Bentonite(20%solids) Other <br /> Grout Placement Method mped 1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By }[Driller Pump Contractor Other <br /> Concrete Pedestal 1 'Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HPPump 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 /> jOAQ.'–"N COUNTY OP,D!NANCES, STATE LAWS �,yn RULES ANID RE ULATiCNS. I fa_SO CERTIFY THAT MY REQUIRED LICENSE IS r– <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL VIII <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM- 24 OU DVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED y�({04 �LJ�- TITLE DATE t ) <br /> i <br /> v` <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> I � <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />