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WELL/PUMP PERMIT F <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT UALL (ZUU) UO3-tbUt FOR INSPECTIONS JtAF'IKLtS 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS .26t� �S` �� /�- CITY/ZIPP /� rc 7S3jW <br />CROSS STREET L ,% ryp IZOa� AP o& 0 - Q,;[ (} 3 PARCEL SIE ],&-U LAND USE APPLICATION # <br />OWNER NAME ( r ' F I Dy Q Q VQ ke M I A 4 C4) PHONE <br />OWNER ADDRESS '�:Sa 48eel CITY/STATE/ZIP <br />CONTRACTOR ���� lr, 1 1r1LtL'ICi(/ �T I P%�_ jPHjONE �Zti -3(� /-370 <br />L <br />CONTRACTOR ADDRESS C�L'� �rt�c�li % I cr (/i��'�, CITY/STATE/ZIP bC% I 1 eq cis -.7W <br />SUBCONTRACTOR �� Jr� PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE W-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: water bystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well [—]Well Alteration/Modification ❑ Other <br />E] Monitoring Well(s) # of wells (,Soil Boring(s) L # of borings # of borings Geotechnical �1 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casinq <br />WMud Rotary ❑Air Rotary oAuger E] Cable Tool E] Push Point ❑ Other <br />Depth ft Excavation y_ (2 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size <br />in diameter) <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />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 I r t e✓l; �- ❑ 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 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 />MI U' 124 HOUR rCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �� TITLE6e;teellniC �t/fT 1'7a*1,6PV' DATE ' <br />T <br />1 <br />m <br />v <br />0 <br />m <br />m <br />DEPARTMENT USE ONLY 'I /� / <br />Application Accepted By ����_ (�' Date `> ' J / Y Area z J 6f k L, Employee ID# A h PI"r <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date _ <br />Soil Boring Inspection By W" Date 6 <br />COMMENTS <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />`/ <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />/ <br />