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"hat smn �i;/' 7 <br />FV tr <br />WELL/PUMP PERMIT <br />S,?N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NU N-KEFUNDABLE PERMIT <br />I I VALL I1Uy `J5 -/by <br />JOB ADDRESS S <br />6 <br />❑Cross -Connection Repair <br />/ <br />-306) <br />CROSS STREET <br />APN <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool E] Push Point <br />OWNER NAME <br />I - w <br />OWNER ADDRESS <br />ft <br />CONTRACTOR <br />❑Plastic E] Stainless Steel E] Other <br />CONTRACTOR ADDRESS <br />❑ Sand Cement sack mix/7 gal water <br />SUBCONTRACTOR <br />A 9 <br />A / I -A- <br />SUBCONTRACTOR ADDRESS <br />LICENSE E-57 ❑ C-61 ❑ D-09 ❑ Other <br />/ FOR INSPECTIONS � ,t:AIJIKtb 1 TEAR FROM DATE ISSUED <br />NUMBER <br />CITY/ZIP �-Jf4 X 7f a (--r-1 <br />0/?Zi <br />C..��EL SIZE C'� l LAND USE APPLICATION # <br />4i�-- <br />0 / 04 PHONE Zi/�y0 <br />/�/ 1- - <br />CITY/STATE/ZIP 11!e"l L / Lf J � <br />PHONE tvLaqiqul <br />CITY/STATE/ZIP(A <br />PHONE <br />CITY/STATE/ZIP <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification <br />❑Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings # of borings <br />❑Geotechnical <br />❑Out-Of-Serviceell ❑Out -Of -Service Well Renewal <br />❑Cross -Connection Repair <br />❑ New Pump NjPumpReplacement ❑ Pump Repair <br />❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool E] Push Point <br />❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth <br />ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel <br />❑Plastic E] Stainless Steel E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) <br />❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant <br />/ Accelerator (name) <br />PEDESTAL Installed By ❑ Driller []Pump Contractor ❑ Other <br />F1 Concrete Pedestal dimensions: Width ft Length ft Thick in []ChristyBox ❑Stove Pipe <br />PUMP] Submersible ❑Turbine [-]Other HP -1 lg2e Pump Sett 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 />E <br />D PARTMENT U E TNLY <br />Application Accepted B 1 Date Area_ l Employee ID# <br />I Nzw� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By / Date 'r o ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />Ln <br />I <br />m <br />v <br />0 <br />m <br />m <br />cn <br />PE SC <br />Codes Info <br />Receivedeck# Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />. p <br />o I S l a--`1 z8 i 1 j, -` c Z lQ Z <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />