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1.3 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />GALL LU9 953-7697 FOR INSPECTIO S <br />EXPIRE5 7 YEAR FROM DATE ISSUED <br />JOBADDRESS <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />-1 . . <br />M6,�. <br />CROSS STREET i YIL <br />,/� <br />,J <br />A/ Iht C✓'.'r <br />APN <br />e�./�/ PARCELSIZE&77W <br />LAND USE APPLICATION# <br />OWNER NAME <br />HONE <br />Q� <br />OWNER ADDRESS}^ <br />J <br />CITYISTATE/ZIP <br />K <br />e e <br />k f 4 <br />eqc, �j <br />t is <br />CONTRACTOR <br />ti "Y^ <br />/ $ <br />CONTRACTOR ADDRESS <br />J v/ <br />0 'r]e f <br /><. It ,P�HONE <br />✓";M•wCITY/STATE/ZJP <br />7 y• . klm cig <br />SUBCONTRACTOR a <br />jj <br />-/ <br />7LV�' <br />F 00 <br />PHONE �� / <br />ff <br />SUBCONTRACTOR ADDRESS U - <br />"`- CITY/STATE/ZIPCA/ <br />y <br />IS,2 <br />y �� <br />7 <br />LICENSE )(G57 <br />❑ C-61 D D-09 <br />D Other <br />NUMBER w <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) 0 Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private 0 Inigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 76,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 D Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings )( Geotechnical# of bonngs <br />❑ Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary Ik Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth S -_lid 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 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth ft A Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mixrl gal water <br />❑ Bentonite (20% solids) 0 Other <br />Grout Placement Method'_Pumped ❑ Free Fall 0 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP 0 Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level It <br />1 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 />MINIM M 241 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95$-7697• <br />SIGNED J /lN TITLE J 7� 1'� K �I 1� DATE <br />U1 <br />D <br />X <br />m <br />N <br />m <br />Area Employee 10#/� <br />❑ SPECIAL ell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 6/61/16 WELL /PUMP PERMIT <br />EIS TMS�Y <br />Application Accepted By <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />�J <br />Date <br />COMMENTS <br />U1 <br />D <br />X <br />m <br />N <br />m <br />Area Employee 10#/� <br />❑ SPECIAL ell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 6/61/16 WELL /PUMP PERMIT <br />