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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 />NON-REFUNDABLE PERMIT ,, CALL (209) 953-7697 FOR INSPECTIONS _1 EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR A2 <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ADDRESS <br />CITY/ZIP <br />S_ <br />APN 10 11 9 e-) e) PARCEL SIZE L �` LAND USE APPLICATION # <br />6l PHONE��_,;51— (0 <br />CITY/STATE/ZIP <br />PHONE�l <br />CITY/STATE/ZIP <br />PHON <br />CITY/STATE/ZIP <br />LICENSE )]p-57 E] C-61 ❑D-09 ❑Other NUMBEPN:r(_'S f�j ( y EXPIRATION DATE e .ul <br />DOMESTIC%ELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ ublic Water System <br />If different from Owner: Water System Name on ac ame or one Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well [-]Well Alteration/Modification ❑Other <br />ElMonitoring Well(s) # of wells ❑ # of borings Soil Boring(s) ❑ Geotechnical # of borings <br />F-1 Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />[]New Pum um Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑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 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 ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <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 />R ADVANCE NOTICE REQUIRED <br />SIGNED <br />- PLEASE CALL (209) 953r7697 <br />DATE _7/ <br />T <br />M <br />a <br />0 <br />0 <br />m <br />m <br />rn <br />l7E ARTM E NT lJS 0 L <br />Application Accepted ELy Date Area Employee ID# <br />�' <br />Grout Inspection ByDate ❑ SPECIAL Well Permit <br />Pump Inspection By Date -c) ed I I i ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC <br />Codes Info <br />Received <br />By <br />ec <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />