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` 7 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />/� ,,� <br />�I /J <br />> <br />CITY/ZIP `�/ <br />rn <br />m <br />/ / P / / �7i <br />CROSS STREET APN _ f (�/ <br />����" •� / PARCEL $IZEf & LAND USE APPLICATION # <br />o <br />OWNER NAME Ny✓rd-/V <br />c � <br />n/✓.�/�� �(J PHONE / �xy�'_ -/dZjy <br />vi <br />� <br />OWNER ADDRESS <br />✓ /T�� !% <br />/ 7L -i CITY/STATE/ZIP <br />/LJA <br />CONTRACTOR /// //;�//f"W <br />�►i�yC <br />J"i �'- / PHONE <br />CONTRACTOR ADDRESS<f�E--Ci� <br />Iy=g <br />r <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />PHONE ^� <br />SUBCONTRACTOR ADDRESS e— CITY/STA <br />TE/Z <br />IP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 rOther NUMBERr[/11 EXPIRATION DATE /l 1 <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USEbomestic/Private ❑ Irrigation/Agricultural ❑ Industrial LI 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 ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump lkrumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom LI Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 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 U Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP submersible ❑ Turbine I I Other HP �_ Pump Set j24LQ ft Standing Water Level / l' 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 U NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95? -7697 <br />SIGNED TITLE DATE I 2 <br />DEPARTMENT <br />Application Accepted By ✓ Date i <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />CJMMENTS <br />Date <br />USE ON LY <br />.')?-1) <br />Area I �l `/ Employee ID# <br />❑ SPECIAL Well Permit <br />[7 WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc Received <br />Info B <br />Check#/ Amount Date Permit/ Invoice # Well ID# <br />Cash Remitted Service Request # <br />3�1 <br />vSv <br />15 9 3 S7 -7 <br />21 D 3 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />