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f A <br /> • ' ' WELLIPUMP 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 INSPECTI NS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -\ rA <br /> JOB ADDRESSr ITY/LP <br /> O <br /> CROSS STREET AP PARCEL SIZE LAND USE A4LICATION# m <br /> OWNER NAME PHONE <br /> f <br /> OWNER ADDRESS � ITY TATEIZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATFJZIP <br /> LICENSE C-57 i i C-61 L D-09 a Other NUMBER L EXPIRAnON DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section-- �.r <br /> INTENDED USE 7 DomestiC/Private irrigation/AgricuHural L.Industrial ❑Water Quality Monitoring n Soil Sampling/Characterization <br /> �Public Water System G1 7 <br /> If different from Owner Water Systern Narne o a arae or one um er <br /> TYPE OF WORK J^ew Well _ Replacement Well Well Alteration/Modification Other <br /> Q <br /> n Monitoring WellR of borings 0 of borings IOs) #of wells 1 Soil Boring(s) r Geotechnical >=) O <br /> I Out-Of-Service Well Out-Of-Service Well Renewal 1;Cross-Connection Repair �� <br /> Q) <br /> H New Pum C Pump Replacement C Pump Repair r Raise Well Casing X -17 <br /> WELL CONSTRUCTION <br /> Drilling Method f Mud Rotary L Air Rotary _Auger -j Cable Tool i Push Point ­� Other j <br /> - (-J E <br /> Proposed Well Depth 7 O ft Excavation 18y�in diameter ❑Open Bottom 9-'Gravel Pack/Gravel Size in di O7 <br /> !,Conductor Casing in diameter / Conductor Casir T Depth ft . V <br /> Well Casing Diameter—�in TTidme�/Gauge/ASTM Sched YY y� steel P Ic C Stainless Steel, ,i Other ftf Cy C <br /> Grout Seal Depth O ft gAeat Cement(941b bag/5 10 gal watery Sand Cement 3/)L sack mix!!gal 1= C LO <br /> F-1 Bentonite(20%solids) n Other +_* Q7 =' <br /> Grout Placement Method I,Pumped Free Fall C Other a Retardant/Accelerator(name) -O C-- <br /> PEDESTAL <br /> PEDESTAL Installed By ❑Driller P-Pump Contractor _ Other <br /> u Concrete Pedestal LDimensions:Width ft Length It Thick in a ChristyBox a Stove Pipe L— <br /> i <br /> PUMP a Submersibleu Turbine :j Other HP Pump Set ft Standing Water Level <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT^ <br /> NO ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE COMPENSATION LAWS. <br /> INIM 4 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-P EASE CALL(209)953-7697 <br /> n 1 y <br /> SIGNED ! TITLE ©��-eZ y`�1' DATE - , I <br /> A�V�FNT <br /> Yp7,?014 <br /> �Fo <br /> i�EFU111111 MrF <br /> k 011V CO <br /> 41 <br /> ra I • nip EPgRTME� <br /> r;[7 <br /> I <br /> by <br /> DEPARTMENT USE ONLY <br /> Application Accepted By ` Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPE�C-IALW@II P@Rrii[ <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS Wti t L w —L rOl:t�p'(- <br /> PE Sc Received Chec Amount Date Service <br /> Invoice# Well IDN <br /> Codes Info Remitted Service uest# <br /> `� <br /> EHD12 R L(,QA Y-YWr �'.'A <br /> 4/30n 2 K wF1L(PUMP <br />