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- WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-HEFUNDABLE PERMIT <br />JOB ADDRESS v\ <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />CALL LUy V!)J-/by/ FOR INSPECTIONS tAFIHtS 1 YEAR FROM UATE ISSUED <br />�\,oq CITY/ZIP i 1, q �(� 3 `N <br />APN V PARCEL SIZE AND USE APPLICATION # <br />y41[4 PHONE <br />I CITY/STATE ZIP Q3 <br />Cp� ` PHONE <br />�1 CITY/STATE2IP Slvt r� <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE `C-57 C-61 D-09 Other <br />CITY/STATE/ZIP <br />3')� )'IC' EXPIRATION DATE <br />3EOGRAPHICAL INF RMATION: Coordinates X Y Township Range Section <br />NTENDeD USE Domestic/Private i Irrigation/Agricultural I Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK I I New Well i, Replacement Well I I Well Alteration/Modification I 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 rump I Hump Heplacement I I rump Hepalr i Halse well casing <br />WELL CONSTRUCTION <br />Drilling Method 1 I Mud Rotary I I Air Rotary Auger I I Cable Tool Push Point I Other <br />Proposed Well Depth ft Excavation in diameter 1 Open Bottom ri Gravel Pack/Gravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic 1 Stainless Steel Other <br />Grout Seal Depth ft I Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) i Other <br />Grout Placement Method i 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 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 CALIFO A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C ATION LAWS. <br />INIMU 4 HOUR V OTICE REQUIRED FORN3PCTIONS -PLEASE CALL (209) 953 697 <br />SIGNED y TITLE DATE <br />D PARTMENT USE ONLY <br />Application Accepted By Date <br />} t Grout Inspection By Date <br />Pump Inspection By r I Date_ <br />Soil Boring Inspection By D.ite <br />COMMENTS <br />Area Employee ID# <br />MLAL� <br />SPECIAL Well Permit <br />CI WAIVER Received <br />Constructed Well Depth __ ft <br />PE <br />Codes <br />SC <br />Info) <br />Received <br />B <br />Check#/ <br />Cas[h� <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />