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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 0 <br /> 5 m <br /> JOB ADDRESS CITY/ZIPWL' CA 9 D <br /> .� y O <br /> CROSS STREET / W APN PARCEL SIZE � I AND USE APPLICA(TIIOON##y� rn <br /> OWNER NAME PHONE( — <br /> OWNERADDRESS ` CITY/STATE/ZIP (illi r�/`T —b �( <br /> CONTRACTOR I PHONE <br /> CONTRACTOR ADDRESS aD` CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE',-` <br /> SUBCONTRACTOR ADDRESSY STATE/ZIP ` <br /> LICENSE -57 ❑ C-611 ❑ D-09 [I Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: 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 /> I YPE Or-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 Pump VPurnp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION ix <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 lb bag/5-10 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 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 COUNT`! 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 CO PENSATION WS. ,�� <br /> UM,�4 HOUR ADVANCE NOTICE 5FQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE Z <br /> +L <br /> T <br /> DEPARTMENT USE ONL�Y <br /> Application Accepted By Date 0 W Area ( Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �wGal� lPtuz.: U�2 Date V WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE- SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> X13 x o s o Q124 7 7 c3 fo 20 1N P00 (Q t <br /> EHD 43.06 WELL/PUMP PERMIT <br /> 8/04/08 <br />