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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 CITY/ZIP m <br /> D <br /> 0 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# 33 <br /> M <br /> N <br /> OWNER NAME PHONE ur <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE P C-57 7 C-61 1 D-09 I Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE -i Domestic/Private [J Irrigation/Agricultural i.-i Industrial I Water Quality Monitoring a Soil Sampling/Ch r ' en+r <br /> I Public Water System /� <br /> If different from Owner: Water System Name Contact ame or Phone Number D <br /> TYPE OF WORK ❑ New Well 1 Replacement Well J Well Alteration/Modification I Other JUN to <br /> F-1 Monitoring Well(s) If of wells I Soil Boring(s) n of borings Geotechnica #oYbAM16 <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal 1 1 Cross-Connection Repair EENV/ UIN OUNTy <br /> I New Pump Pump Replacement 1 Pump Repair Raise Well Casing EALTH pNNAIE _rAL <br /> WELL CONSTRUCTION ENT <br /> Drilling Method I I Mud Rotary i I Air Rotary I Auger Cable Tool i i Push Point Other <br /> Proposed Well Depth ft Excavation in diameter 11 Open Bottom "I Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel L] Plastic -1 Stainless Steel 11 Other <br /> Grout Seal Depth ft 1 Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mW7 gal water <br /> 1 1 Bentonite(20%solids) I Other <br /> Grout Placement Method I I Pumped 1 Free Fall 11 Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller I Pump Contractor 1 1 Other <br /> i Concrete Pedestal iDimensions:Width ft Length ft Thick in 1 Christy Box 1 Stove Pipe <br /> PUMP _1 Submersible) I Turbine ' 1 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <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 PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 3�8'8�3 <br /> 3 8' z <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 4/30/12 <br />