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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIROy.tN1At HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT�1 `C,AL�Ay6 09)95.3=7L97E0R_ INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 ` 1 ��G V `y i% `' l' CITY/ZIP /�S <br />CROSS STREET APN 10'5 ), ly 3 _r PARCEL SIZE " C1 IG' LAND USE APPLICATION <br />%#� <br />OWNER NAME t \ 6���2 / h uc V S U U PHONE C Lo ClJ {' f5C l R <br />OWNER ADDRESS i -% j fA CITY/STATE/ZIP <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />PHONE <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 I_I Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring F1 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 />)j(NeW Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter Ll Open Bottom I-1 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 I I Neat Cement (94 Ib bag/5-10 gal water) LI Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 11 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other CI Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor LI Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP YSubmersibleuTurbine ❑ Other HP Pump Set Zb t7 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 />MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIG ' TITLE L),��n e, z DATE <br />DEPARTMENT USE <br />Amount <br />Remitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />- <br />- <br />++ONLY <br />Application Accepted By <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />Date <br />'-1 <br />Area I () Cl Employee ID# <br />❑ SPECIAL Well Permit <br />E WAIVER Received <br />Constructed Well Depth <br />r i <br />VE <br />M <br />v <br />0 <br />m <br />U) <br />,A h m,, r/ <br />Y <br />PE Sc Received (ng- <br />Codes Info B sh <br />Amount <br />Remitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />I h 1 <br />fl - y <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />