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WA IELLOPUM P PERNT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL I-IEALTI•I DEPT 9368 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 9 YEAR FROM DATE ISSUED <br />f <br />JOB ADDRESS <br />r <br />[� <br />��e��^ <br />CIT'/ZIP <br />Date Permit/ Invoice # <br />Service Request <br />mr <br />CROSS STREET <br />�Jn / J <br />C=1! i`i t/J 07(J �V J PARCEL SIZE • 7(/ LAND USE APPLICATION # <br />D <br />� <br />r P <br />aS I <br />m <br />OWNER NAME <br />� SS2E'' -00,k <br />C- <br />PHONE ( <br />OWNER;'*.DDRESS C <br />q� <br />O { l7 <br />�/_+ <br />S (� �� Y �� 1 CIT'/STATE/ZIP <br />r 1 e <br />CONTRACTOR <br />�a� <br />PHONE <br />CONTRACTOR AD DRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE(ZIP <br />PHONE <br />(LICENSE D C-57 ❑ C-611 ❑ D-09 ❑ Other NUMBER ExPIRATION DATE <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 on acName or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal Cross -Connection Repair <br />ivevv <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 ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-90 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box D 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—ANCTIVE WITI•I THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT .I AM IN COMPLIANCE WITH ALL <br />`JUt7RKERS COMP sATiO&I.L1lll!$, -\ y$ <br />MUM ?J�@�OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />TITLE DATE <br />,PA I MENTI US O ILY <br />Application Accepted By Date �� V <br />Grout Inspection By Date <br />Pump Inspection By Yl 4D Date 7 <br />Soil Boring Inspection By Date <br />COMMENTS G ;P)D(J (4A4? O <br />Area A Employee ID#_� <br />SPECIAL AH Permit <br />WAIVER Received <br />Constructed Well Depth e <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />BA sh <br />Amount <br />Remitted <br />Date Permit/ Invoice # <br />Service Request <br />Well ID;;` <br />EHD 43-06 WELL/PUMP PERMIT <br />8/04/08 <br />