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t <br />WELUPUMP PERMIT r <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-342`0 <br />I`"UN-REFUNDABLE IVERMIT <br />L:ALL ZUV) V0J-1tWf FOR INSPEGI IUNS <br />e= ;_.Mr_7 I TLAK I-KUIVI LIAIt IJJuGu <br />JOB ADDRESSCITYRIP <br />Amount <br />Remitted <br />Date <br />1 <br />CROSS STREET <br />OWNER NAMEIf <br />APN O O <br />f LVI <br />PARCEL SIZE D, LAND USE APPLICATION #_ I <br />r"" PHONE <br />OWNERADDRESS I I <br />CITY/STATE/ZIP LolA�_� <br />If <br />CONTRACTOR <br />wpoo <br />FE IT <br />PHONE �+ <br />CONTRACTOR ADDRESS <br />1- <br />CITYISTATE/ZIP <br />'w!S; <br />SUBCONTRACTOR <br />142 <br />1A <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 'I C-61 D-09 <br />i <br />P Other <br />NUMBERLI QC <br />I <br />EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: Coordinates X _ _ Y Township Range __ Section___ <br />INTENDED USE jl Domestic/Private C Irrigation/Agricultural f ] Industrial ❑ Water Quality Monitoring U Soil Sampling/Characterization <br />1 Public Water System <br />If different from Owner: titer ystem-Nam —eContact Name or Phone Number <br />TYPE OF WORK i i New Well Ll Replacement Well ❑ Well Alteration/Modification U Other <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings L Geotechnical of <br />0 Out -Of -Service Well Ll Out -Of -Service Well Renewal U Cross -Connection Repair <br />New Pump Pump Replacement ❑ Pump Repair 1,1 Raise Well Casing_ <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary 5 Air Rotary i ! Auger I Cable Tool C Push Point FI Other <br />Propo_ed Well Depth_... ft Excavation _ in diameter 7 Open Bottom ri Gravel Pack/Gravel Size__ iq ar{Ieter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel CI Plastic " Stainless Steel =i Other__ <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cementsack mix/7 gal water <br />I Bentonite (20% solids) ' I Other <br />Grout Placement .9ethod [ I Pumped _l Free Fall Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By '_7 Driller ❑ Pump Contractor a Other <br />Concrete Pedestal I Dimensions: Width ft Length It Thick in L Christy Box f -I Stove Pipe J <br />PUMP Submersible I! Turbine Other HP Pump Set It 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 />uMMM M 24 HOUR ADVANCE NOTICE REQUIRED FO INSPECTIONS - PLEASE CALL (209) /9�53�769t <br />SIGNED " TITLE 0I)AW DATE ¢1<1 / L —� <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS A'0 L <br />Date <br />_ Date <br />____ Date <br />-r k� (qq <br />Area Employee ID# " <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />PE <br />Codes <br />Sc <br />Info <br />Received <br />By <br />he T_' <br />ash <br />Amount <br />Remitted <br />Date <br />Permit <br />Service Request # <br />Invoice # <br />Well ID# <br />74 <br />wpoo <br />FE IT <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/12 <br />