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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT '1868 East Hazelton Avenue - S;TOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS (�l CITY/ZIP <br />CROSS STREET 440b TAIU I APN " 9�0 O — I L�PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME HONAA E <br />OWNER ADDRESS �n1 CITY/STATEIZIP <br />CONTRACTOR J PHONmo,nw�a& V91 9�,✓/►/ <br />CONTRACTOR ADDRESS -22/` CITY/STATE/ZIP <br />SUBCONTRACTOR /� //► PHOW 44 <br />SUBCONTRACT R ADDRESS STATE/ZIP <br />LICENSE C-57 ❑ C-61 ElD-09 ❑ Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFO MATION: Coordinates X Y Township Range Section <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ 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 ❑ Cross -Connection Repair <br />❑ New PUm7 Pump Replacement ❑ 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 �-:cavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter I 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/5-90 gal water) ❑ Sand Cement sack mix17 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 1 -IP Pump Set fi�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 />WORKE OMPENSATION LAWS. 10 <br />( iAAAhh I I M HOUR ADVANCE NOTIC '"jR//�j//E^QUI EEDF�OR INSPECTIONS [•�' <br />SIGNED TITLE �YA WI/,(1 DATE —{ <br />e DEPARTMENT U E ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection ByDate <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />PA <br />Area EmditM P4 <br />IL <br />S ECIAL 'Well Pe Ph 0 <br />WAIVER Receu�;'ff p 1 4 2018 <br />Constructed Well Dept ft <br />'UruUAz.,..._ UIN cn/ r.��.. <br />T <br />m <br />D <br />0 <br />M <br />m <br />N <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />cbc <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request# <br />Invoice # <br />Well IN <br />EHD 43-06 WELL /PUMP PERMIT <br />8/04/08 <br />