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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NOWREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET APN D PARCEL SIZE C t t LAND USE APPLICATION # <br />OWNER NAME J r `� rY U PHONE <br />OWNER ADDRESS _?) o� `� �♦1 %'j� �i f.' v Y / CITY/STATE/ZIP �J C�( IC�/yam //�/ 7 <br />CONTRACTOR �ILC�GtVI')�(��If��� /�Cc"_r--,t�`/l� �G� ISI Jf ��-V%l PHONE / �S / �CJ/-40IGLX11�[ <br />CONTRACTOR ADDRESS 45 .] V �I�f-l/L � C)0 C- 1 Y �J e__ CITY/STATE2IP L/ tJe-ki,?n,/ ,— <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 1_ C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />INTENDED USE Domestic/Private j Irrigation/Agricultural _j Industrial a <br />Public Water System <br />If different from Owner: Water System Name <br />, <br />TYPE OF WORK I New Well Replacement Well I_l Well Alteration/Modification <br />it Monitoring Well(s) _ It of wells ❑ Soil Boring(s) N of borings i Geotechnical a of borings <br />11 Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />Township Range Section <br />V Soil Sampling/Characterization <br />Contact Name or Phone Number <br />New Nump Hump Heplacement I I Nump Hepalr Halse Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary Air Rotary Auger r Cable Tool Push Point Other <br />Proposed Well Depth9e?D ft Excavation '� in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter/lD in Thickness/Gauge/ASTM Sched `-<` ; A Steel Plastic ❑ Stainless Steel Other <br />Grout Seal Depth 4 ft i Neat Cement (94 Ib bag/5-10 gat water) (, Sand Cement / D sack mbd7 gal water <br />Bentonite (20% solids) LI Other <br />Grout Placement Method i Pumped 11 Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor Other <br />Concrete Pedestal 'Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine 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 />IMINIMU 2 O F ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 -7 7 <br />SIGNED/TITLEL1.! I.� �� DATE /� / <br />DEPARTMENT USE ONLY <br />Application Accepted By j F h J/� td 9 ULA L�� Date > > <br />Grout Inspection By _ Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area 90 ___ Employee ID# - <br />RA <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rn <br />m <br />m <br />D <br />v <br />v <br />m <br />rn <br />PE <br />Codes <br />SC Received <br />Info By <br />Che Amount <br />Cash Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice #II ID# <br />_1111-71 101"k KyrP <br />EHD 43-06 WELL/PUMP PERMIT <br />4130/12 <br />