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WELUPUMP PERMIT <br /> SAN J080014 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 _ _.. CITYIZIP D <br /> 0 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# m <br /> M <br /> OWNER NAME PHONE to <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 *j-C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 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 Omer: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,arNeW Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> u>New Purne ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary ❑ Air Rotary I i 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 Schad _I Steel Plastic Stainless Steel ❑ Other <br /> Grout Seal Depth _ ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mW7 gal water <br /> ❑ Bentonite(20%solids) - Other <br /> Grout Placement Method .64Pumped I Free Fall If Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By �"Driller r Pump Contractor. ❑ Other <br /> Concrete Pedestal Dimensions:Width ` it Length ft Thick in ❑ Christy Box Stove Pipe <br /> -'PUMP i-I Submersibles 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 ^ O ACTIVE W;TH THE CALIYVR.NiA CONTRACTORS STATE LICENSE 50AFiD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> ------------------------- <br /> --------------------------- <br /> J A UI IO N <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date -1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth _ ft <br /> COMMENTS --- <br /> - '--i <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> WELL/PUMP PERMIT <br /> EHD 43-06 <br /> 4/30112 <br />