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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 /> JOB ADDRESS/ + L/ I I ` CITYRIP <br /> II l D <br /> CROSS STREETS APIN e 1 ��S moo` PARCEL SIZE l -''NAND USE APPLICATION# <br /> OWNER NAME In+ ' r�,'�JC!(/I/� ` ' 1 PHONE 20 ` 4 <br /> OWNER ADDRESS, � f�1l L/V `7 ` 1 , <br /> CITY/STATE <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/i <br /> SUBCONTRACTOR -_ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township._ Range Section <br /> INTENDED USEomestic/Private Irrigation/Agricultural LlIndustrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: ater ystem Nameontact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modificat' p `. <br /> if +" f 4 of borin s <br /> ❑ Monitoring Well(s)_- #of wells ❑ Soil Boring(s) 9 ❑ Geo Gectf(.tic 9ut-Of-Service Well ❑ Out-Of-Service Well Renews rnnection Repair h <br /> New Pum i Pum Replacement Fl Pump Repair i I a ;;� '''fired wift ink:t <br /> WELL CONSTRUCTION h n. J <br /> Drilling Method Mud Rotary LlAir Rotary Auger n Cable Tool Push Pol Omer <br /> Proposed Well Depth ft Excavation in diameter Op'WBWo)n r0q]@Aa t 0&"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 wafer) ❑ Sand Cement sack mii 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 HP Pump Set it 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 /> WORKERS COMPENSATION LAWS. <br /> NIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CAU�209)953--7 97 <br /> SIGNE TITLE �� o� '"' "� _ DATE I <br /> d <br /> e• <br /> t <br /> c.+ <br /> !> 1 i <br /> .1, �,` <br /> ( <br /> S <br /> DEPARTMENT USE ONLY <br /> Application Accepted By n— ✓L 4 _.__ Date � / Area ' a1 Employee ID# � <br /> Grout Inspection By _ Date — _ _ IJ S ECIAL Well Permit <br /> Pump Inspection By _- Date iWAIVER Received <br /> Soil Boring Inspection By ___ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> 4 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />