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W <' -//;; 4 <br />WELLIPUMP PERMITFi23��&'* 'o <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue - STOCKTON CA 95205-6232 - (209) 468-3420 n �, <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />r� <br />JOB ADDRESS CITY/ZJ,! �rpr !//r/ %� m <br />CROSS STREET N r l/j— ///(/" PN (/ / �O �� �I�� PARCEL SIZE /6, LAND USE &PPLICATION # <br />S s AOA)7fes aF ,� G/�S �.y cD.v-P� 111 -mos- q3 <br />OWNER NAME ' <br />OWNER ADDRESS <br />CONTRACTOR !/�l "�'��5 %'`/! �N� ��J� p PHONE�l-2/ C/ <br />CONTRACTOR ADDRESS � � ZO W�L-GD�- /G� CITY/STATE/ZIP <br />7: 95 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS �� CITY/STATE/ZIP <br />LICENSE -57 ,<t-61 ❑ D-09 ❑Other NUMBER �VEXPIRATION DATE Z <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 Uontact Name or Phone Number <br />TYPE Or- WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ 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 />❑ New Pump XPumpReplacement ❑ 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 PaCIdGravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b 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 D Christy Box ❑ Stove Pipe <br />PUMP ills ubmersible❑' Turbine ❑ Other HP Pump Set 17--e ft -Standing Water Level 010 ^ ft <br />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, yu <br />D PARTMENT YSE 911NLY <br />� <br />Application Accepted B Date �" Area �-- Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring <br />COMMENTS <br />Constructed Well Denth <br />-2-2 <br />PE <br />Codes <br />SC Received <br />Info By <br />Check# <br />aas< <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service/Request # <br />Invoice # <br />Well ID# <br />r <br />rod <br />EHD 43-06 WELL /PUMP PERMIT <br />8/04/08 <br />