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WELUPUMP PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 e�__^ A %I -- • riwTr 1 HCr1 NON-REFUNDABLE PERMIT CALL (2U9) UbJ-/b`.f' / FUH INSNtG I LUNO Jnr rr/nw/'0 I �•+� •• •�••• --^ • - ---- Eno ash Amount R mitted Date C LIP JOB ADDRESS V o� Well ID# CITY/ZIP �Af 1 \\ CROSS STREET / ` 12D—APN 0-3 PARCEL SIZEZ�LAND USE APPLICATION # -17— A PHONE 20S— OWNER NAME OWNER ADDRESS yarn 2. V `ill"\t/� 1tJF 1 l� CITY/STATE/ZIP \ t`-' ' PHONE )-1vRG��1�j CONTRACTOR v v` CONTRACTOR ADDRESS CO)( C CITY/STATE/ZIP )lf� l( , ` �� 'I / u SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS (CITY/STATE/ZIP ' LICENSE C-57 f) C-61 i 1 D-09 N Other EXPIRATION DATE_Ui___4__ GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE^t Domestic/Private [-j Irrigation/Agricultural ❑ Industrial i] Water Quality Monitoring ❑ Soil Sampling/Characterization /[, Public Water System If different from Owner: Water System Name ontact ame or Phone umber TYPE OF WORK ❑ New Well (I Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair # of borings P New Pum Pump Replacement ❑ Pump Repair [7 Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool U Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom i-1 Gravel Pack/Gravel Size in diameter Ll Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter in Thickness/Gauge/ASTM Sched 'J Steel 11Plastic C Stainless Steel ❑ Other Grout Seal Depth ft [; Neat Cement (94 ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water 1 Bentonite (20% solids) [ I Other Grout Placement Method i_] Pumped _-, Free Fall Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other Concrete Pedestal F. Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible [-.I Turbine r; Other HPA_ Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. ftl"MUM AD AINCENCI ICE REQUIRED FO INSPE TIONS -PLEASE CALL (209)�951-(76 J5II ) 76 7rrQ� SIGNED ult a, TITLE DATE L Y �( 1 fij, bARTMENT// U 'E 0 L Application Accepted By %� Date b 1 t Grout Inspection By Date Pump Inspection By Date Soil Boring Inspection By Date COMMENTS Area '7+ Employee ID#AM" ❑ SPECIAL Well Permit Cl WAIVER Received Constructed Well Depth ft to D PE Co Sc Info Received B Eno ash Amount R mitted Date Permit/ Service Request # Invoice # Well ID# EHD 43.06 WELL/PUMP PERMIT 4/30112