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,• WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT f CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDR9 V 3 /'J4�/r% ,////� J/fI— /(�/T CITY/ZIP —7 /kG1<' /C/' ! cy— <Tj <br />C i <br />CROSS STREET J A N 9_0q 0`5 3 PARCEL SIZE 6. N S LAND USE APPLICATION # <br />M � <br />OWNER NAME ` �K�/ y(//�'L GLP �lfl� /j PHONE <br />OWNE,t ADDRESS <br />CONTRACTOR a <br />jj� <br />yC Pl l <br />CONTRACTOR ADDRESS /Q41'5v&_a4 del -0 &4 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE N C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />PHONE �f /' '9hX—�2 4 <br />CITY/STATE/ZIP���������� <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <9-7'.J i / <br />DOMESTIC WELL SAMPLING: [-]General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ADomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Uontact 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 <br />❑Geotechnical <br />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br /># of borings <br />LXNew Pump UF'ump Replacement UPump Repair [_j Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool F1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑Other <br />in diameter <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib 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 qVump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width L ft Lengthft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP (Submersible❑Turbine ❑Other HP r Pump Set ft Standing Water Level R0 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 AOTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA\TtON LAWS. <br />MINI.NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9�5,3-7697 <br />D77;F� <br />T <br />SIGNED TITLE //� i.Z� DATE ''/ Z—/ �/7 <br />r <br />m <br />D <br />0 <br />v <br />M <br />m <br />N <br />rp <br />DEPARTMENT USE ONLY <br />41 <br />Application Accepted By2)6 Date ,- �D Area I <� LI Employee ID# r <br />Grout Inspection By Date 0 ❑ SPECIAL Well Permit <br />Pump Inspection By Date� E] WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount <br />asRemitted <br />Date Permitt Invoice # Well ID# <br />Service Request # <br />0 <br />USG <br />,damp- <br />P�Gi37/3� <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />