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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 DAT E ISSUED <br /> / m <br /> JOB ADDRESS /��/� CITY/ZIP m <br /> rte =_D77-�j D <br /> CROSS STREET ^� y i�11�Ny � 4 P/AR�CELJSI]ZE O� / LAND USE APPLICATION# m <br /> N <br /> OWNER NAME L—�/�/ �i��Nry" ! `�l%/V � '�'✓C7V PHONE <br /> OWNER ADDRESS }-//�. CITY/STATE/ZIP F. `f 7 ZV <br /> CONTRACTOR /�� PHONE /�� ��j <br /> CONTRACTOR ADDRESS `l /��J/�—��'/� CITY/STATE(ZIP _1~ L;` v;�S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/S <br /> STTAT <br /> )E/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER W O/ EXPIRATION DATE �� ? <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 0 Public Water Systern <br /> If different from Owner: WateT System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br /> 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 0 Geotechnical #of borings <br /> ❑ Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump -.99urnp Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pacic/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> ❑ Concrete Pedestal Dimensions:Width fl Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level <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.1 AM IN COMPLIANCE WITH ALL <br /> WORKERS C P SATION LAWS. <br /> UM HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / <br /> SIGNED �iGL'� TITLE �i DATE <br /> flys <br /> A. <br /> oO <br /> -- — — J <br /> H V/ ri /N <br /> IVY <br /> AEjPTIVIENT USE ONLY ` ,Application Accepted By Date Area �/ Employee ID#��6f^- <br /> Grout Inspection By n1 Date SPECIAL Well Permit <br /> Pump Inspection By Vt ,Siu) g&j-j'," Y L DateI Z 0_0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedeck Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> EFID 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />