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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT UALL ZUy UO3-1b9l FOR INSPECTIONS EXPIKE5 1 YEAR/ FROM DATE ISSUED <br />JOB ADDRESS ��� 1 L"J ,, �� f (ec jj CITY/ZIP T I. "' y <br />CROSS STREET IKLyae APN .7�, �� S �.1) PARCEL SIZE q.* I t)r. LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />re <br />CONTRACTOR ADDRESS ' Ca Z 114101164,i <br />SUBCONTRACTOR SLL /i: <br />SUBCONTRACTOR ADDRESS <br />LICENSE W-57 ❑ C-61 ❑ D-09 ❑ Other <br />au( V PHONE: C'1 <br />(AV _ "132504 <br />CITY/STATE/ZIP C(4f q, qS2 7� <br />PHONE <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 614"9EXPIRATION DATE b, <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 System Name Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well <br />❑ Replacement Wel I ❑ Well Alteration/Modification El Other <br /># of borings # of borings <br />El Monitoring Well(s) # of wells ❑Soil Borings) Geotechnical <br />❑Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />New Hump UHump Replacement <br />Raise Well Casl <br />Drilling Method ( Mud Rotary ❑Air Rotary rRAuger E] Cable Tool F1 Push Point ❑ Other <br />Proposed Well Depth.& -6-V ft Excavation 44'' ' in diameter E] Open Bottom E] 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 ❑Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag15-10 gal water) ❑ Sand Cemmeent� sack mix17 gal water <br />❑ Bentonite (20% solids) $Other G,pI L_ CL! f'rlAi+q f , Vll, C�yGc1UiC�JiC*�t� _ <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal O)imensions: Width ft Length ft Thick in [_]ChristyBox ❑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 />DEPART1MENT USE ONLY <br />CApplication Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Ad,/�,n / ,, , <br />Soil Boring Inspection By AjAK(�py` �/f' '6 Date l / <br />COMMENTS <br />Area Employee ID#A*m,&,- <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />M <br />T <br />PE SC Received <br />Info B <br />Check#/ Amount <br />Cash Remitted Date <br />Permit/Codes <br />Service Request # Invoice # Well ID# <br />P <br />F`1 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />