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a <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />JOB ADDRESS c <br />CROSS STREET J <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />=RMIT CALL 209 953-7697 FOR INSPECTIONS LAF'IIKtS 1 YEAR FROM UATE ISSUED <br />CITY/ZIP <br />WC yo QCJ-21S <br />` �A/P�N 20S _1q 02 PARCEL SIZE �- 1 LAND USE APPLICATION # <br />PHONE <br />��// L D 1(r'1 q I W <br />CITY/STATE/ZIP S "' k- IJ 1' � C+ <br />CAYIS C1 � PHONE 2" - IQ3 / 32i 2 <br />2VV 1 <br />12© , W/ 2S )/J - CITY/STATE/ZIP Sjv(:k jCA — 15- <br />/ PHONE / <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />❑ D-09 ❑ Other <br />CITY <br />�'/STATE/ZIP <br />NUMBER l/n1MU EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private rrigation/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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />F1 New Pump rtPump Replacement F-1PumpRepair C1 Raise Well Casinq <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 />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 />SIGNED <br />E CALL (209) 9C}5 <br />DATE / <br />r <br />m <br />O <br />0 <br />m <br />m <br />DEPARTMENT <br />gUSE ONLY <br />Application Accepted By Date 1 - <br />Grout Inspection By Date <br />Pump Inspection By Date z% <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area `) / % Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received <br />Codes Info B <br />ec Amount to <br />ash Remitted <br />Permit/ Invoice # Well ID# <br />ervice Request # <br />S- zsyu <br />. <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />