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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 />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />LICENSE <br />GALL (ZU9) UOJ-/by/ FOR INSPECIIUN5 <br />) ADDRESS - <br />C-57 I] C-61 i] D-09 [I Other <br />_z1"a- <br />CITY/ZIP <br />:EL SIZE <br />r sfi <br />CITY/STATE/ZIP <br />CArIMr-0 I T tNn mum via I c waucu <br />D <br />QAND USE APPLICATION # m <br />ON �V � rn <br />CITY/STA <br />PHONE <br />1/STATE/ZIP <br />EXPIRATION <br />aEOGRAPHICAL IN RMATION: Coordinates X Y Township Range Section <br />NTENDED USE Domestic/Private E Irrigation/Agricultural ❑ Industrial l., Water Quality Monitoring ❑ Soil Sampling/Characterization <br />[l Public Water System <br />If different from Owner: ater System Name Contact Name or Phone Number <br />TYPE OF WORK F1 New Well a Replacement Well ❑ Well Alteration/Modification ❑ Other <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection ReDair <br />❑ New Pump A Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary [; Auger ❑ Cable Tool U Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 'j Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 1 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />[I Bentonite (20% solids) '. I Other <br />Grout Placement Method [ I Pumped '=1 Free Fall C Other [' Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 7 Pump Contractor ❑ Other <br />Concrete Pedestal ;'Dimensions: Width it Length ft Thick in ❑ Christy Box IF, Stove Pipe <br />PUMP Submersible[! Turbine I ; Other HP Pump Set y (-1 ft Standing Water Level ft <br />I HEREBY CER FY THAT 1 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 />WORKE gOMPENS ION LAWS. <br />MI I H F A AN E N ICE REQUIRED FOR IINSSPjECTAOO�NSS -PLEASE CALL (209) 95 -769 <br />SIGNED (� / TITLE XYYT '/.�� G� !/'�j 1 DATE <br />EP RTMENT USE O LY <br />Application Accepted By Date <br /><" <br />Grout Inspection By Date <br />Pump Inspection By _ II Date b 0 _ <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />L WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc <br />Inf�o(� <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 />as <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />