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r rG <br /> WELL/PUMP PERMIT LSD <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(2Q9)953-76J7 FOR INS ECT.LONJ EXPIRES 1/YEAR FROM DATE ISSUED <br /> r ^ 9 <br /> JOB ADDRESS vdor1CITY/ZIP '1 m <br /> CROSS STREET APN —J PARCEL SIZE LAND USE APPLICATION# m <br /> � hh <br /> OWNER NAME IN /` ` V PHONE ( r(ln ur <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> ' <br /> CONTRACTOR ADDRESS C. ,CN CITY/STATE/ZIP 07 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 1 <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER -32 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name (;ontact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement >00-ump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ 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 ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ 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) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ 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 /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORN CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMP TION LAWS. <br /> 4 H DVANCE NOTICE RECUIRED FOR INSPECTIONS <br /> SIGNED TITLE /�✓✓ DATE 4 <br /> ce <br /> J <br /> is <br /> J <br /> PAIQ <br /> O O <br /> C <br /> 1 <br /> dDA.R ENT U E O LY <br /> Application Accepted By Area "l 1 Employee ID# <br /> _J(�� <br /> Grout Inspection By Date PECIAL Well Permit <br /> 1L <br /> Pump Inspection By,f f?l6w a Date E laV 1Cl WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received KMeck#p Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> 05 <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 8/04/08 <br />