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0 <br />• WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />CALL (ZUy) <br />U0J-1by/ FOR INSPECTIONS <br />LAII'll1t%J "I TEAK FKUM UAIL ISSUED <br />JOB ADDRESS' <br />CITY/ZIP <br />CROSS STREET!/ <br />O <br />S 3 2 Go Z PARCEL SIZE V <br />LAND USE APPLICATION ##/ <br />OWNER NAME // <br />nom`%�� <br />�✓ &24", �� L�IAA✓ <br />,AQPNN <br />PHONE / <br />3Z — /b e/ z <br />OWNER ADDRESS <br />cJ� <br />C.ITY/STATE/ZIP <br />�J <br />CONTRACTOR <br />D✓YJ'/� <br />�J!Z <br />d`-s'K— <br />PHONE <br />CONTRACTOR <br />CONTRACTOR ADDRESS/ <br />j�l�/jw <br />CITY/STATE/ZIP <br />.3� IN✓ <br />C / -/ UIJI <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />1 ❑ D-09 1-I Other <br />CITY/STATE/ZIP <br />NUMBER yU'& EXPIRATION DATE -2/44 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring LI 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 �] Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings LI Geotechnical # of borings <br />❑ Out -Of -Service Well fJ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New PUMD 3JPUmD Replacement f 1 PumD Repair ❑ Raise Well Casinq <br />Drilling Method ❑ Mud Rotary �] Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter U 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 H Steel Ll Plastic LI Stainless Steel ❑ Other <br />Grout Seal Depth ft 1_1 Neat Cement (94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped 1l Free Fall ❑ Other [I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 11 Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Vsubmersiblell Turbine El Other HP__L1 <br />Z Pump Seth 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 O ANCECE NOTICE REQUIRED FOR �IN EECTTII�ONS - PLEASE CALL (209) 9/53,-769 <br />SIGNED TITLE <br />DATE / <br />DEPARTMENT USE ONLY �J <br />Application Accepted By Date l " , Y Area 1 G� Employee ID# uC"% <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date i ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />.11 <br />A, <br />PE SC Received Che Amount <br />Codes Info B Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest # <br />t p 0 v <br />�3 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />