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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 />NON -REFUNDABlor PERMIT . CALL 12091 953-7697 FnP INCPFr.TIONC FXPIPFR 1 YEAR FRr11U nATF ICCI IFn <br />JOB ADDRESS 1 . �I P <br />CROSS STREE PN 21 ZkPARCEL SIZE LAND SE PPLICA ION # <br />) <br />OWNER NAME HO <br />OWNER ADDRESS I CITY/STATEIZIP <br />CONTRACTOR//OWN <br />CONTRACTOR �- �..- O f <br />ADDRESS 1 CITY/STATEIZIP oma- <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS I TA /ZIP <br />LICENSE C-57 _ C-61 D-09 Other NUMBER EXPIRATION DAT • / j^ <br />GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br />INTENDED USE D Domestic/Private Xlrrigation/Agricultural r.. Industrial Water Quality Monitoring - Soil Sampling/Characterization <br />J Public Water System <br />Ifdifferent from OwnerWater byStaro Name contact Name or Prone Number <br />TYPE OF WORK—,4New Well Replacement Well I Well Alteration/Modification Other <br />-. Monitoring Wells) # of wells - Soil Boring(s) *of borings -- Geotechnical ° <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />- New Pump Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method >1ud Rotary Air Rotary 1 Auger Cable Tool Push Point Other <br />Proposed Well Depth_;22*_fC, ft Excavation in diameter D Open Bottom -,/Gravel Pack/Gravel Size in diameter <br />L Conductor Casing in diameter / Con ucto5Casin Depth <br />Well Casing Diameter Thickness/Gauge/ASTM SchedjZ4 <br />_In D SteelPlastic I StainlessSteel r_: Other <br />Grout Seal Depth �`/ ft :_ i Neat Cement (94 /b bacy5-10 gal water) Sand Cement �[�/� • �f sack mix/7 gal water <br />- Bentonite (20% solids) - Other <br />Grout Placement Method L Pumped I_ Free Fall _: Other .7 Retardant / Accelerator (name) <br />PEDESTAL Installed By -� Driller Pump Contractor Other <br />Concrete Pedestal _ Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />PUMP _ Submersibleu Turbine Other HP Pump Set ft Standing Water Level ft <br />I nCKttlY t-tKllt-Y THAI I HAVt 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 COMPLIANCF WITH AI I <br />VT <br />ED <br />/� rt r m <br />Application Accepted 6y �- �(Date O Area Employee ID#�G / !l tIl iff <br />Grout Inspection By Date -1 SPECIAL Well Permit <br />Pump Inspection By Date 7 WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date Constructed Well Depth ft <br />EHD WELL /PUMP PERMIT <br />A/30/1212 <br />