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WELL/PUMP PERMIT P� / <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PER.MryIT` /}CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM <br />YDATE ISSUED <br />JOB ADDRESS�t� 5 /i` _ CITY/ZIP <br />CROSS STREET '4N©A i� SLAPN Ina 01 Lv PARCE'SI <br />LSIZE LAND USE APPLICATION #/ Q <br />OWNER NAME �r��✓ �Nv`� L J �' J e) - /7 r PHON�� <br />OWNER ADDRESS W(7 WV A'\�_�.+� CITY/STATE/ZIP 11 - S/ <br />CONTRACTOR ''Ift oorc-- ,may �'/s 4%j C 6/� �! PHONE 0�� ) ?;, Z/ t) <br />CONTRACTOR ADDRESS F � � L Z�/ 1 — � /' CITY/STATE/ZIP "'i o' �71rn Qt--, <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE C-57 1� C-61 Ll D-09 7 Other NUMBER 4WC15�) jo EXPIRATION DATE (CI <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private I -I Irrigation/Agricultural LI Industrial I I Water Quality Monitoring 1.1 Soil Sampling/Characterization <br />11 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Ll Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 11 Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I I Cross -Connection Repair <br />❑ New Pu <br />lacement ❑ <br />11 Raise <br />Drilling Method I I Mud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool ❑ Push Point 1_1 Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom LI Gravel Pack/Gravel Size in diameter <br />LI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel P Plastic I I Stainless Steel LI Other <br />Grout Seal Depth ft I.1 Neat Cement (94 Ib bag/5-10 gal wate/) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 1_I Other <br />Grout Placement Method ❑ Pumped I I Free Fall I I Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor L Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ubmersible❑ Turbine n 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 />MIN 2r4 O %�j�ANCE NOTICE REQUIRED FOR INNSP/E/CTITIOiNS - PLEASE CALL (209) 953-769 <br />SIGNED /-'� TITLE_//L/Z✓/� C DATE �–� <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENTUSE N L Y <br />Date <br />Date <br />Date <br />Date <br />f <br />Area Employee ID# �n <br />❑ SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE SC Received Amount ate Permit/ Invoice # Well ID# <br />Codes Info ash Remitted Service Request # <br />77 r W -7 Lf <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />T <br />m <br />D <br />v <br />0 <br />X <br />V) <br />En <br />0 -3 <br />