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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-REFUKDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP m <br /> D <br /> 0 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# <br /> M <br /> N <br /> OWNER NAME _ PHONE N <br /> OWNER ADDRESS _ CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE i C-57 C-61 i D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private _ Irrigation/Agricultural a Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water ystem Name Contact Name or Phone umber <br /> TYPE OF WORK " New Well Replacement Well I Well Alteration/Modification Other <br /> I Monitoring Well(s) #of wells i Soil Boring(s) #of borings I Geotechnical #of borings <br /> i Out-Of-Service Well i Out-Of-Service Well Renewal i Cross-Connection Repair <br /> New Pump i Pump Replacement I Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 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 in Thickness/Gauge/ASTM Sched ❑ Steel Plastic Stainless Steel r1 Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) Other <br /> Grout Placement Method i Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I Driller Pump Contractor Other <br /> Concrete Pedestal '7Dimensions:Width ft 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, STATS LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> Ct1R9ENT AND ACTIVF WITH THE CALIFORNIA CONTRACTORS STATE_ LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL (209)953-7697 <br /> SIGNED TITLE DATE <br /> 60-97 9 <br /> o d01JV111NO3 t7-3SN'1011 L00 70 E4(]H3 <br /> p N <br /> ?o <br /> W <br /> C <br /> ------- — lueO!Iddd ---- ala❑ <br /> -sasodlnd uolloadsul aol Apadoid pauolluaul-anoge a41 uodn aalue of Alunoo <br /> SIL41 10 sanllelueseudaa azlao4lnu Aclalatl pup 'uollonalsuoo walsAs abomas.Io pup uollonalsuoo paM of bullelal smul atels pup s93ueulpl0 <br /> dlunoo pup Allo Ile gl!M Aldwoo of 00i6e I •loaaaOD s! uollewaOlul anoge a4) lagl ©gals pup uo!le011ddp slyl peaa enpg I lagl A1!U00 I <br /> #)!waad r(la1e3 le11)snpul 10 u0!s!A!p [] <br /> •uO!S!A!p a4l WOa1 TOM 4ons op of 1!waad e sp4 UOSAad 4ons ssalun 'anoae <br /> pqlou se 14191eS lelllsnpul 10 uols!Ala a4l woal lruued e aalnbei pinoM 4o14M Miam op of auoAue Aoldwe lou II!M I 'aapl!nq-aaurnO sd GI <br />