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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />JOB ADDRESS A -4L <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRES <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />L;ALL (1U!:1) U53-11JUI FOR INSPECTIONS tAI`IKt5 "I YEAR FROM UATE ISSUED <br />r K-�(,(ILA CITY//ZIP ZV L jt (JLV <br />AAPN [�Q /) (' 10 of PARCEL SIZED©� LAND USE APPLICATION # <br />t�rJ VL j��JS�CI` J PHONEC.CJ`�t- 30 - �SJ <br />CITY/STATE/ZIP <br />/ t•U;/��LT / jV � PHONE / ' �y <br />CITY/STATE/ZIP UI &b L�� qa <br />PHONE %(..�t_/`�I 5, -?0- Lq� <br />TY/STATE/ZIP L <br />LICENSE N-57 ❑ C-61 ❑ D-09 11Other _ NUMBER / EXPIRATION DATE ! `.J/ ` <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section _ <br />INTENDED USE 11Domestic/Private Irrigation/Agricultural LIIndustrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water system Name Uontact Name or Phone Number <br />TYPE OF WORK lew Well ❑ Replacement Well I 1 Well Alteration/Modification LI Other <br />❑ Monitoring Well(s) # of wells LiSoil Boring(s) # of borings i I Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />U New Pump 1 i Nump Keplacement u rump Kepalr u Kalse vveii uasmg <br />WELL CONSTRUCTION <br />Drilling Method L Mud Rotary L] Air Rotary El Auger /❑ Cable Tool Ll Push Point F1 Other <br />Proposed Well Depth _§ ft Ilft Excavation ain diameter ❑ Open Bottom - ( Gravel Pack/Gravel Size in diameter <br />11 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diametervl_-in Thickness/Gauge/ASTM Sched I I Steel ❑ Plastic LI Stainless Steel ❑ Other <br />Grout Seal Depth Go ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />CI Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller LI Pump Contractor D Other <br />❑ Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Box o Stove Pipe <br />rPuMP I I Submersible Turbine 11 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 />MINI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI//((��NS - PLEASE CALL (209) 953-7697 <br />SIGNED `�7 - TITLE -`GSL DATE( <br />D E PARTMENT USE ON LY f <br />Application Accepted By �,.d�— Date 10/91 Area fTc Employee ID#f LO <br />Grout Inspection By G D Date // ZZ r 612714 ❑ SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS WeII DElly, <br />Date <br />Date <br />WAIVER Received <br />Constructed Weil De <br />hvn .in C1a77i <br />ft <br />T <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />a <br />aD <br />�l � <br />�� 7�%3.�'PTIMMIT <br />a <br />o 5- 0 <br />s � <br />Fig <br />EHD 43-06 WELL /PUMP PERMIT <br />4130il.') <br />