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WELUPUMP PERMIT <br />SAN JOAOUIN 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 />JOB ADDRESS — —1 lY ►v1 ! !Il I/! _ CITY/ZIP Ch1 <br />CROSS STREET w , 'v �_ C� � 1 APN (R S L U D Cj PARCEL SIZE -� r� LAND USE APPLICATION # <br />• giwIMIRIAMPI! UrArAWF��I��n�� <br />OWNER ADDRESSI II� �il J <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />9 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 A-61 D-09 Other NUMBER <br />PHONE1(% �,1• �'ll <br />CITY/STATE/ZIP I _Z2J2— <br />PHONE 1,U� <br />CITY/STATE/ZIP 1�� <br />PHONE <br />CITY/STATE/ZIP <br />EXPIRATION DATE___' <br />GEOGRAP IiCAL INFORMATION: Coordinates X Township Range Section <br />INTENDED USE Domestic/Private Irrigation/Agriculturaltri ater Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />111*lth .42K <br />If different from Owner: Water SvsteContact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well ❑ Well Alterati atioW Other <br />Monitoring Wells # of wells 7 Soil Boring(s) s of borings tt of borings <br />",/ g () g() Geotechnical ��YIIAEli191, <br />IeOUt-Of-Service Well IJ Out -Of -Service Well wal Cross -Connection Repair <br />New Pump Pump Replacement 1-1 Pump Repair Raise Well Casing r1te:tIVED <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point <br />Proposed Well Depth _ -, _____ft Excavation in diameter Open Bottom <br />Conductor Casing in diameter / Conductor Casing Depth <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel ❑ Pla <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-f0 gal water) n Sat <br />Bentonite (20% solids) Other <br />Other <br />APR 13 2015 <br />aa <br />Gravel Pack/Gra �l' AQUIN COU11` Iyer <br />LINIMENTAL <br />ft HEALTH pE PAHTMENT <br />>tic Stainless Steel Other <br />d Cement sack mix/7 gal water <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Co_ggj tg Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />Pu efrible Turbine Other HP Purnp Set It Standing Water Level ft <br />! H E ERWE <br />AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQU),N COtJES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURa,�t1.'6 AND THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINW 11 I HOUR/IADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DEPARTMENT USE ONLY <br />Application Accepted By ' DateA Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date CI WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date_ - <br />Constructed Well Depth <br />ft <br />rn <br />rn <br />D <br />0 <br />m <br />in <br />U) <br />PE <br />Codes <br />SC <br />Info <br />ReceivedCheck <br />B <br />Amount <br />Remitted <br />Date <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />EHD 43-06 WELL /PUMP PERMIT <br />4/30/' 2 <br />