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' WELL/PUMP PERMIT <br />I : SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLEPERMIT UALL ZU9 953-7697 FOR INSPECTIONS f EXPIRES 1�iYEAR FROM DATE ISSUED <br />JOB ADDRESS 6 5'S -O 19/4 xtTG (Z -) . CITY/ZIP � l< el C `/ ` S �0 <br />CROSS STREET �� z Sr APN -�=� SQ % PARCEL SIZE 3. S.5 LAND USE APPLICATIONo# <br />OWNER NAME 4eRAJI Pn m -bo / '/_� <br />PHONE0� <br />OWNER ADDRESS JJ O J Cl V/��f� / '4$�/V• CITY/STATE/ZIP 7_RA �j ems('' �s 30! <br />CONTRACTOR ��� �% %✓� �d �/`[ / /� [PHHONE �Q 7 —AGyJ� <br />CONTRACTOR ADDRESS 13179 S /'%I��� �/j t? r 0, CITY/STATE/ZIP F � (, 6 C"14 `_ i! <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE JCC-57❑ C-61 ❑ D-09 ❑ Other <br />CITTY/STATEIZZIP_ <br />NUMBER 52 J <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural jonclustrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water bystem Name on acName 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 />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casinq <br />WELL CONSTRUCTION <br />Drilling Method L] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool L] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter [-]Open Bottom ❑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 E] Stainless Steel E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b 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 dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine []Other HP Pump Set O 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 />/1MVUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 e� e <br />SIGNED TITLE -6 CT A)G /` DATE U <br />DEPARTMENT USE ONLY <br />Application Accepted By f - Date 1 " U �) Area .S Employee ID# I" h 01(/ <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pumo Inspection By Date F J ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date Constructed Well Depth <br />ft <br />T <br />m <br />a <br />v <br />v <br />m <br />m <br />v, <br />PE <br />Codes <br />Sc Received Check#/ <br />Info B Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8101/16 WELL /PUMP PERMIT <br />