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4 WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEWENT 304 E WEBER 1D FL - STOCKTON CA 95202 - (209) 468-3420 <br />A Vlr-KEFUNDABLE rERM1T LI LI, tLU9) W).5- /DY / FOR INSPEC -11ONS rxrix b I Y EAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET APN PARCEL SIZE LAND USE APPLICATION <br />OWNER NAME PHONE <br />OWNER ADDRESS CITY/STATE/ZIP, <br />CONTRACTOR <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP, <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER <br />PHONE <br />PHONE <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />NTENDED 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 <br />❑ Monitoring Well(s) # of wells <br />❑ Well Destruction <br />❑ Well Alteration/Modification ❑ Test Hole ❑ Other <br />❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal <br />U tvew rump u rump Kepiacement u rump Kepatr u k-ross-t,onnectlon Kepatr <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 <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /># of borings <br />in diameter <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) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted <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 CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINI1IUM 24 HOUR ADVANCE NOTICE REQUIRE D FOR INSPECTIONS <br />SIGNED TITLE DATE <br />Application Accepted By. <br />Grout Inspection By <br />Pump Inspection By. <br />Destruction Inspection By, <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date <br />Date <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info By <br />Check#/ Amount Date <br />Cash Remitted <br />Permit/ <br />Service Request # <br />Invoice # <br />Well ID# <br />EHD 43-02-006 WELL PUMP PERMIT <br />8/6/04 <br />