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rn,i h'a( Can ►i jz <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)466-3420 <br /> NON-REFUNDABLE PERMIT �-' CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> m <br /> JOB ADDRESSt CITY/ZIP G <br /> CROSS STREET L APN[/ ��/W�O PARCEL SIZE Q_ LAND USE APPLICATION# m <br /> OWNER NAME PHONE <br /> �' to <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE 4�vq <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP /��!// i�� `✓ � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> r,' 2J <br /> LICENSE I; ,C-57 `) C-61 [J D-09 n Other NUMBER EXPIRATION DATE <br /> GEOGRAPH16ALINFORMATION: Coordinates X Y Township RangeSection <br /> INTENDED USE Domestic/Private n Irrigation/Agricultural ❑ Industrial I:; Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> [ Public Water System <br /> If different from Owner: Water System Name ontact ame or Phone umber <br /> TYPE OF WORK 0 New Well 11 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical If of borings <br /> 0 Out-Of-Servicell ❑ Out-Of-Service Well Renewal [j Cross-Connection Repair <br /> ! New Pump 7CPump Replacement U Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth tt 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 — L3 Steel ❑ Plastic Stainless Steel 0 Other <br /> Grout Seal Depth ft Cl Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br /> CI Bentonite(20%solids) [J Other <br /> Grout Placement Method ;I Pumped D Free Fall F Other [_ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in 0 Christy Box P Stove Pipe <br /> P!Rrr^ I Submersible[; Turbine I; Other HP ,/ Pump Set ft Standing Water Level ft <br /> 1 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 /> M 41, 1 NCE NOTICE REQUIRED FOR INSPECT NS- PLEASE CALL(209)953-7-u-*/ <br /> SIGNED TI_MwT EX DATE <br /> Al MA-1 )I-'- <br /> ( <br /> Q rt tt2 <br /> Eff I N AE 4TL <br /> T/• E VI .E <br /> P0 I <br /> AQ <br /> pf F <br /> F — <br /> �PARTMENT US ONLY ��—;-� <br /> Application Accepted By Date L57AreaEmployee ID#rQQ v <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth tt <br /> COMMENTS_ <br /> PE SC Receivedhec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />