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i <br />t I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VERRMITc� ' > L;ALL (ZU9) 953-7b97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS a �/ /V('1L����C��J CITY/ZIP <br />CROSS STREET A P N ! — �F (/ I PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME ,r~j C� / PHONE <br />f�7 <br />OWNER ADDRESS " CITY/STATE/ZIP <br />CONTRACTOR/ S�—S., PHONE <br />CONTRACTOR ADDRESS '2 //Ve5 CITY/STATE/ZIP <40,t/ `*4� ✓Z� 117 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE IN C-57 [XC -61 ❑ D-09 ❑ Other. <br />PHONE <br />CITY/S <br />/TATE/ZIP (, <br />NUMBER 9 1U t I G' EXPIRATION DATE I I <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water bystem Name ------ C-o—nfact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />❑Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump Wump Replacement ❑ Pump Repair ❑ Raise Weil Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool [-]Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />F1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) []Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller [:]Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ubmersibie❑Turbine ❑Other_ HP Pump Set (Z 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 />W <br />-i <br />m <br />D <br />v <br />v <br />m <br />m <br />N <br />N <br />DE ARTMENT U,5,EyONLY <br />c <br />Application Accepted By Date ` Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date 10 l L ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received <br />Codes Info By <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />-7- <br />tl,`' I <br />0DF R <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />