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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IYVIY-MLIUNDAt$LE r'ERMIMIIT <br />GALIL JZU? FOR INSPECTIONS <br />tAVIII111=0 l YEAR FROM UATE ISSUED <br />/VO4-/Oyt <br />/ <br />'1/ <br />/�`� / <br />Y7 / on <br />JOB ADDRESS J <br />'L�( <br />W' ` <br />CITY/ZIP <br />` <br />CROSS STREET <br />APN <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />c <br />PHONE � ] <br />/V <br />i <br />OWNER ADDRESS <br />CITYISTATE/ZIP <br />L - <br />lk44 <br />-)� rr,, �' <br />CONTRACTOR <br />A) C <br />/ i�-&1W <br />� <br />r <br />�C� <br />`�;PHHON\�[J <br />' <br />ro <br />CONTRACTOR ADDRESS G <br />L1 � N {^ <br />CrTY/STATE/ZI'a.—q <br />� ] <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP <br />J <br />LICENSE -i -G-57 r C-61 D-09 Other NUMBER .-� EXPIRATION <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE � f'Domestic/Private i Irrigation/Agricultural . Industrial Water Quality Monitoring ' Soil Sam piing/Characterization <br />Public Water System <br />If different from Owner Water ZSYSIOM Name UoMaCt Name or one um or <br />TYPE OF WORK .LNeW 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 -0f -Service Well Renewal Cross -Connection Repair <br />New Pum /-Pump Replacement : 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 I 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 bagr5.10 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 y' Other L.' 1.// / I t - <br />Concrete Pedestal :'Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP —Submersibles Turbine - Other HP � % 1 Pump Set ft Standing Water Level <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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE DATE <br />Grout Inspection By Date 1.7 SPECIAL Well Permit <br />Pump Inspection By Date 0 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Request # <br />EHD 43-M WELL /PUMP PERMIT <br />4/30/12 <br />