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. WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP ayD <br /> �J�' <br /> CROSS STREET `j��A�PN /L7 "�`O PARCEL SIZE"•V�LAND USE APPLICATION# <br /> D� Ab'W_0, L PHONE rn <br /> OWNER NAME vi <br /> OWNER ADDRESS CIITTY/STATE21P <br /> CONTRACTOR & ` ^ICI!2�%`�.►7C PHONE <br /> CONTRACTOR ADDRESS 7 L�� ��L4T JJ"�� � CITY/STATEIMP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP 1 <br /> LICENSE \C-57 0 C-61 0 D-09 0 Other NUMBER — — EXPIRATION DATE l Nv I <br /> BILLING PARTY: ❑OWNER D CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private O Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> I1 different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings 0 Geotechnical If of borings <br /> ut-Of-Service Well � /.t,�0 Out-Of-Service Well Renewal 0 Cross-Connection Repair . <br /> 0 New Pump D Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter V Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter idY In Thickness/Gauge/ASTM Schad Ateel u Plastic 0 Stainless Steel C Other <br /> Grout Seal Depth It 'u Neat Cement(94 Ib bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> C Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor C Other <br /> 0 Concrete Pedestal ODimensions:Width it Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible0 Turbine O 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 /> MINI UR CE NOTICE REQUIRED FOR IN ECTIONS-PLEASE CALL(209)953;-7f,,97rA,q <br /> SIGNEDITLE L DATE <br /> .10 <br /> RFl M <br /> 54/v <br /> OF�1 FO <br /> I �'o- <br /> Al <br /> 1�?0 <br /> rpq� CNrr <br /> ---i7�7 <br /> I <br /> DEPARTMENT USEONLY <br /> Ln <br /> Application Accepted By Date_ �� �O,(� Area Employee ID# r►` <br /> Grout Inspection By Date '+� SPECIAL Well Permit <br /> -Rua l;Inspection By C C i.r11 .j 1 y T_l7_�Q.:(,Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ScfIJ PC' J1 o vie 11 1$ fn 111nl G n H ? l�/P is well <br /> 5 '4' 'A e C i /)l <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well IN <br /> Codes Irdo as Remitted S 1 R quest# <br /> EH043-06 6111rM9 WELL/PUMP PERMIT <br />