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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H DEPARTMENT 600 EAST MAIN STREET KToN CA 95202-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYMP <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITYISTATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIMP <br /> LICENSE i l G57 7 C-61 i i DA9 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural C Industrial Water Quality Monitoring Sal Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water SYStM Name Uordact Nam or one u er <br /> TYPE OF WORK New Web ❑Replacement Well C Well AkeraB Other <br /> Monitoring Weg(s) #of wags Sal Bor #of borings <br /> kng(s) =GeGeotechnical #of borings <br /> Out-OI-service Wag E Out-Of-Service Wait Renewal ❑Cross-Connection Repair <br /> New PumpPump Replacement ❑Purnp R Raise Well Casi <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary _Air Rotary Auger ❑Cage Toa 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 It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel [ Plastic Fj Stainless Steel E Other <br /> Grout Seal Depth it ❑Neat Cement(94 Ib bag/r10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method J Pumped L;Free Fag a Other R /Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor J Omer <br /> Concrete Pedestal Dimensions:Width it Length It Thick in ❑Christy Box ❑Stove Pipe <br /> P MP Submersibleo Turbine Li Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 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 <br /> SIGNED TITLE DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHO 43-08 WELL/PUMP PERMIT <br /> 8/04/08 <br />