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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 />r1. r In <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ADDRESS <br />CALL (2U9) yb3-lb9/ FOR INSPt:c I IUNb <br />Xc__ CITY/ZIP <br />PN PARCEL SIZE L, <br />LICENSE I q-57 r7 C-61 r) D-09 ❑ Other <br />GEOGRAPHI L NFORMATION: Coordinates X <br />Y <br />NUMBER <br />CITY/STATE/ZIP <br />CAr-IIIGJ 1 1 F-P%n r-nvm vn�� wvvw <br />USE APPLICATION # <br />VE�' T �� <br />1 � � _ � /., /lam-• . i.� <br />I.9&A0F&W� /i PAONE=jffM.Alf P�CITY/STATE/ZIP (jPHONE <br />r" <br />EXPIRATION DATEf <br />Township Ranoe Section <br />INTENDED USEDomestic/Private E Irrigation/Agricultural ❑ Industrial J Water Quality Monitoring ❑ Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well I1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service IF❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />�A�_�41AEF'An- <br />WELL <br />P,w Neum LiRe lacement Pum Re air [IRaise Well Casin CONSTRUCTION11'p I <br />Drilling Method Ll Mud Rotary ❑ Air Rotary I -] Auger Ll Cable Tool L) Push Point 11 Other I V <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave4ize ��?fk#tpmeter <br />❑ Conductor Casing in diameter / Conductor Casing Depth it �flt j0'4/N <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 'j Steel ❑ Plastic ❑ Stainless Stee'IlEq� , p � IT , <br />Grout Seal Depth ft [ i Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cementf�r/i> gal water <br />LI Bentonite (20% solids) 1 Other T <br />Grout Placement Method i 1 Pumped D Free Fall t7. Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br />Concrete Pedestal CDimensions: Width It Length ft Thick in ❑ Christy Box r? Stove Pipe <br />PUMP Submersible[; Turbine r: 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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERMMPENSAIION LAWS. <br />SIGNED <br />EP RTMENT USE I Y <br />Application Accepted By c Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area dql Employee ID#A,VI.% <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Che <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />Ojai(a <br />w 20.4qu <br />LHU 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />0 <br />rn <br />m <br />En <br />