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WELUPUMP PERMIT <br />SANIJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />CALL (209) 953-7697 FOR INSPECTIONS <br />EXXPIRE�Sn1'YEAR FROMDATEISSUED <br />JOB ADDRESS� <br />i R <br />ZpQ��d,'—' <br />-F A 0--- <br />_ CITY/ZIP <br />Out -Of -Service Well <br />CROSS STREET <br />1 <br />�//c-IL" d,' -'I- <br />C <br />_PARCEL SIZE <br />LAND USE APPLICATION # <br />Raise Well Casing1 <br />/ <br />�APPIN <br />V� <br />9DC.--/J <br />OWNER NAME <br />l G CiI�L�I <br />_-�j <br />F Other <br />PHONE t Z- <br />OWNER ADDRESS <br />^� ©� / <br />C' <br />CITY/STATE/ZIP <br />CONTRACTOR <br />/ <br />��f�r��[ <br />C <br />/ <br />PHONE <br />CONTRACTOR ADDRESS <br />Grp <br />I �_ `I P4 / s" <br />[V%��'tl <br />S' ►Z,J <br />_1 <br />CITY/STATE/ZIP <br />ma4e <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 ❑ C-61 a D-09 Il <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER � ��{' P L- EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USEDomestic/Private I I Irrigation/Agricultural a industrial i Water Quality Monitoring I i Soil Sampling/Characterization <br />Ll Public Water System <br />If different from Owner: Water System Name ontactName or Phone Number <br />TYPE OF WORK >11New Well Replacement Well <br />; Well Alteration/Modification <br />-i Other <br />cl <br />Cash <br />Monitoring Well(s) # of wells <br />Soil Boring(s) # of borings Geo hnica <br />S <br />Out -Of -Service Well <br />Out Of -Service Well Renewal <br />Cross Connectio 46 <br />New Pump 7 Pump Replacement <br />-i Pump Repair <br />Raise Well Casing1 <br />WELL CONSTRUCTION <br />Mud Rotary F1 Air Rotary Auger <br />Drilling Methodly <br />F1Cable Tool i Push Point <br />F Other <br />Proposed Well Depth - zQ ft Excavation IZ- in diameter i I Open Bottom Gravel Pack/Gravel Size in diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched .:W 0 1 SteelPlastic Stainless Steel 1 Other <br />Grout Seal Depth ) ft 1 Neat Cement (94 Ib bag/5-10 gal water) and Cement sack mill gal water <br />'Betentonite (20% solids) Other <br />Grout PlacementMethod Pumped F1 Free Fall ii 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 />rbine I I Other HP PumD Set ft Standing Water Level ft <br />I HEREBYXERT"IrRAT I HAYJ PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN� TATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURREN I CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br />WORKER SATION LAWS. <br />MIN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br />f l i DATE <br />SIGNED t C_. L�1 ��Gi� TITLE �' l IE <br />m <br />0 <br />0 <br />0 <br />M <br />Q) <br />U) <br />r DEPARTMENT USE O LY <br />Application Accepted By ` e 4 Date <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Ins <br />Date <br />Area ` Employee ID# -;%irVII1900 bAJ <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />U� r� mos �s <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />cl <br />Cash <br />Amount <br />Remitte <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />PERINUT <br />EHD 43.06 WELL/PUMP PERMIT <br />4/30/12 <br />