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WELUPUMP PERMIT <br /> SAN JOAOUIN 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 /> Sn <br /> . D �V PJ CITYIZIR li/ (�/� m <br /> JOB ADDRESS __ � �" Z�7 ( M <br /> / �' l l_ L{ o <br /> CROSS STREET I APN O�� �" _"- (PARCEL SIZE 1 \ LAND USE APPLICATION# a <br /> m <br /> OWNER NAMES r �f PHON/E' C i t 1 r N <br /> OWNER ADDRRSS ( (/ CITY/STATE IP [/U ` I ✓ <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 L Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range_ Section <br /> INTENDED USE omestic/Private Irrigation/Agricultural L Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> i_I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well L ff Well Alteration/Mod on t` " L <br /> 11 Monitoring Well(s) p #of wells El Soil Boring(s) _ f Ge ec:lntc 51 # f borings <br /> - ut-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> iI New Pum -1 Pump Replacement ❑ Pump Repair dy-jithrlut <br /> WELL CONSTRUCTION <br /> 'i�.�o� bein9 con,pitAed or inspec I <br /> Drilling Method Mud Rotary L Air Rotary Auger ❑ Cable Tool 1-1 Push P int Other <br /> f �/ 1 ��rnnmui-s� €y` •�, , <br /> Proposed Well Depth ft Excavation in diameter f�A 6dtgm � U4 I Pr-16t Gravel, e' in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched i l Steel Li Plastic L Stainless Steel I Other <br /> Grout Seal Depth ft i Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixJ7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped i Free Fall Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I Driller 1 Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP ❑ Submersiblei Turbine i Other HP Pump Set 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMU 4 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209)953-7697 <br /> SIGNED <br /> V . <br /> TITLE <br /> 2 <br /> rN <br /> �p <br /> O <br /> i v 1 r <br /> 75 <br /> �, 1 r <br /> DEPARTMENT ISE ONLY <br /> 1 {� <br /> Application Accepted By Date ! Area Employee ID# _ <br /> Grout Inspection By Date _l SPECIAL Well Permit <br /> Pump Inspection By Date i 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received #/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> (to Ll L S `k eel <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />