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WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />0 <br />JOB ADDRESS _ <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ADDRESS <br />�I 'FOR ip <br />fAPN /P/APPLICATION # <br />• _ <br />LICENSE �Q-57 rl C-61 i I D-09 ❑ Other <br />EXPIRATION DA <br />GEOGRAPHICAL IN TION: Coordinates X Y Township Range Section <br />INTENDED USE r Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />n Public Water System <br />If different from Owner: Water System Name --------Contact ame or Phone Number <br />TYPE OF WORK ❑ New Well n Replacement Well G Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells C Soil Boring(s) # of borings ❑ Geotechnical n of borings <br />❑ Out -Of -Service WI U Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Cl New Pum C ump Replacement C Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool CI Push Point ❑ Other <br />Proposed Well Depth It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 'j Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />I_I Bentonite (20% solids) :1 Other <br />Grout Placement Method U Pumped =1 Free Fall n Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ', Pump Contractor ❑ Other <br />Concrete Pedestal i --Dimensions: Width ft Length ft Thick in D Christy Box ❑ Stove Pipe <br />PUMP Submersible Turbine I] 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 />WORKEAS COMPENSATION LAWS. <br />SIGNED <br />D C4�PARTMENT U E NLY <br />Application Accepted By Date UZO <br />Grout Inspection By n Date <br />Pump Inspection By , hPl� _ t t Date/0/?ah? <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area llqEmployee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />a <br />v <br />0 <br />m <br />m <br />N <br />N <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />090 <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />