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-1-r4 h ci( (fcgn Ica <br /> WELL/PUMP 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 /> N <br /> JOB ADDRESS ti CITY/ZIP m <br /> -za0CROSS STREET APN PARCEL SIZE LAND USE APPLICATION It a <br /> OWNER NAME ICA f 'PHONE N <br /> OWNER ADDRESS AyrrlCITY/STATE/ZIP <br /> CONTRACTOR9 PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR A PHONE <br /> SUBCONTRAYrI <br /> R ADDRESS ITY/STATE/ZIP�_ <br /> LICENSE -57 `I C-61 it D-09 11 Other NUMBER EXPIRATfDN DATE & <br /> GEOGRAPHI AL INFORMATION: Coordinates X Y Township Range Seetion -, <br /> ItiTENDED USE DomestlC/Private n Irrigation/Agricultural N Industrial Fi Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water SystemNameName or Phone N°m r _ <br /> TYPE OF WORK 17 New Well I I Replacement Well C Well Alteration/Modification C Other <br /> 0 Monitoring Well(s) #of Wells ❑ Soil Boring(s) oI bonngs Geotechnical of borings <br /> 0 Out-Of-Servic ell L Out-Of-Service Well Renewal U Cross-Connection Repair <br /> 4-1 New Pump Pump Re lacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method lJ Mud Rotary G Air Rotary C Auger [7 Cable Toot CI Push Point L Other <br /> Proposed Well Depth_ ft Excavation - in diameter 3 Open Bottom L: Gravel Pack/Gravel Size in diameter <br /> I_? Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched fa Steel a Plastic Cl Stainless Steel L Other <br /> Grout Seal Depth ft D Neat Cement(94 1b bagl5-10 gat wafer) p Sand Cement sack mix17 gal water <br /> 1 I Bentonite(20%solids) f 1 Other <br /> Grout Placement Method I It Pumped 11 Free Fall 7 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller 5 Pump Contractor 1j Other <br /> Concrete Pedestal - Dimensions:Width ft length It Thick in i, Christy Box C Stove Pipe <br /> PUMP IrSubmersible:i Turbine I Other HP Pump Set7=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 /> WORKEV '\\COMPENSATION LAWS. <br /> M I 4 NICE OTICE REQUIRED FO I SPECT ONS - PLEASE CALL (200)948-76 <br /> SIGNED TITL DATE 7 <br /> G <br /> 1 <br /> l DN O L <br /> P <br /> qQ <br /> F <br /> E P A R T M E N T U S �—O N L Y —��y,�,� <br /> Application Accepted By Date tYJ!! Area Employee ID# 1 v <br /> Grout Inspection By Date Ll SPECIAL Well Permit <br /> Pump Inspection By _ Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _- It <br /> COMMENTS <br /> PE SC Received hecIV Amount Date Permit/ Invoice# Well IDN <br /> Codes Info B ash Remitted Service Request# <br /> EHD 43-06 WELLIPUMP PERMIT <br /> 4/30112 <br />