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WELUPUNIV) Pi:-RMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1 fi6fi EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR IN PECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS � �Z 1. � \ � CITY/ZIP <br />CROSS STREET <br />OWNER NAME <br />N 'S C%('0 -- f_3 PARCEL SIZE LAND USE APPLICATION # <br />1. V � o� PHONE <br />OWNER ADDRESS V1� CITY/STATE/ZIP— <br />CONTRACTOR PHONEr�� ,tl b)— iU y <br />CONTRACTOR ADDRESS ` CITY/STATE/ZIP <br />SUBCONTRACTOR ) ri kVA\. V l C1 <br />PHONE <br />SUBCONTRACTOR ADDRESS _ CITY/STATE/ZIP _. <br />LICENSE C-57 C-61 i D-09 I] Other _ NUMBER EXPIRATION DATE -(6 <br />�1 <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_____ <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification I <br />k of bori 't of borings <br />❑Monitoring Well(s) _ 4k of wells F1 Soil Boring(s) eotec <br />F.1 Out -Of -Service Well ❑ Out -Of -Service Well Renewal 1 e <br />New Pum -><P -um Replacement ❑ Pum Re air je <br />WELL CONSTRUCTION <br />Drilling Method L -J Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter Open Bottom r I Gravel Pack/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 I 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 C Pumped ❑ Free Fall I Other ❑ Retardant / Accelerator (name) _ <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP 'NSubmersible" Turbine Other HP / �/Z Pump Set / (CrI ft Standing Water Level `Z U 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 1S <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 24 HOU ADJN NOTICE REQUIRED FOR INSrE¢�TIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ' �4 �`�'14 TITLE_ I / �iifJlJ�� DATE <br />7 A �/9 DE PARTM ENT {USE <br />ONLY <br />Application Accepted By — Date�— <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS C v /kwll "4S , AbAZ <br />i�Y� � r� {�0 'l(� .n, 21.x. �! i tcJ � P rt•,t %�a. " iii r <br />❑ SPECIAL WCH Permit <br />❑ WAIVER Received <br />Constructed Well Depth 7 i ft <br />T <br />D <br />v <br />v <br />m <br />m <br />Cn <br />Cn <br />FA <br />PE <br />Codes <br />SC'Received <br />Info <br />By <br />a <br />Cash <br />Amount <br />Remitted <br />Date <br />_ <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />2onh I" W:% WIIIIFFEIIIM <br />+W 1 <br />co��r <br />1,11S <br />30 <br />ls3 <br />rh <br />EHD 43-06 <br />4/30/12 <br />WELL /PUMP PERMIT <br />