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WELUPUMP PERMIT <br /> SAN JOAOUIN 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 /> — m <br /> CROSS STREET._ _ APN PARCELSIZE LAND USE APPLICATION# <br /> — — — - m <br /> OWNER NAME PHONE N <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 C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township Range Section <br /> INTENDED USE Domestic/Private Irrigation/Agricultural �j Industrial Water Quality Monitoring Soil Sampling/Cha a r ' LVjV! <br /> Public Water System _ _ .__ R <br /> If different from Owner: Water System Name Contact Name or Phone Number D <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other JUN ' Q ,,,_ <br /> Monitoring Well ❑ g »of borings N o bo <br /> Well(s) _-_ #of wells Soil Boring(s)s) GeotechnicalS� <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair EN'ORoU/jv COVN� <br /> New Pum Pum Replacement Pum Repair Raise Well CasingLTH p MFNTq� <br /> WELL CONSTRUCTION ENT <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 Ib bag/5-10 gat water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped 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 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 ! I SPECIAL Well Permit <br /> Pump Inspection By Date ! I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Reg uest# Invoice# Well ID# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />