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WELUPUIOP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS __ _ _. CITY/ZIP m <br /> v <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# M <br /> m <br /> rn <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE i 1 C-57 1 C-61 1 D-09 Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE -, Domestic/Private J Irrigation/Agricultural i Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> 1 ! Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _i New Well Replacement Well I Well Alteration/Modification 1 Other <br /> I Monitoring Well(s) #of wells I- Soil Boring(s) u of borings 1 Geotechnical n of borings <br /> Out-Of-Service Well -1 Out-Of-Service Well Renewal Cross-Connection Repair <br /> C New Pump Pump Replacement L Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 1 Air Rotary Auger -1 Cable Tool Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> -1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I- Steel Plastic 1 Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method ❑ Pumped i Free Fall 1 Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor _ Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box i 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 /> J0AQUiN %OUN-iY ORDINANCES, ;-:TATE _ ,:ti v, "ND Plil ES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS S'rATE LICENSE BOARD AND THA? I ANI iN C,iiOPLiANC: `JJ1?'i ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS- PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE DATE <br /> T <br /> �4 <br /> r E Nry <br /> M <br /> DEPARTM ENT USE O N L Y <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />