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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-KEI-UNUABLE PERMIT G <br />JOB ADDRESS <br />CROSS STREET y IV nn <br />OWNER NAME I!� <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR �^ <br />SUBCONTRACTOR ADDRESS <br />LICENSE i <br />C-57 ❑ C-61 <br />L;ALL LUy UOJ-/by/ FOR INSPECTIONS tXPIhttb 1 YEAR FROM DATE ISSUED <br />V0 U00 /I CITY/ZIP <br />,APN O F PARCEL SIZE / LAND USE APPLICATION # <br />PHONE20q TIl 38 — 7-29�-7 0 <br />❑ D-09 ❑ Other. <br />NUMBER <br />CITY/STATE/ZIP <br />PHO E /� 31-521c) <br />- / <br />CITY/STATE/ZIP �m —J � �d i`J— <br />PHONE 10 A <br />ItCITY/STATE/ZIP _ <br />EXPIRATION DATE <br />DOMESTIC WELL S MPLING: ❑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 Uomact 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 # of borings <br />❑Geotechnical <br />❑Out-Of-Service\fell ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />rl New Pump Ft Pump Replacement F1 Puma Repair n Raise Well Casino <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] 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 [-]Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Benton ite (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 dimensions: 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 CERTntY 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 />CE REQUIRED FOR IN <br />SIGNED <br />DEPARTMENT U E O-N7LI <br />Application Accepte y Dated <br />Grout Inspection By Date <br />Pump Inspection By Date /d / <br />Soil Boring Inspection By Date <br />COMMENTS /S <br />NS -PLEASE CALL A20 TE �)'95�3e 7i to�97f <br />T <br />1 <br />m <br />D <br />v <br />v <br />m <br />m <br />w <br />vi <br />Area q2 -,If 9 Employee ID# A h Inc e <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructedell Depth ft <br />/ CYw e-✓ / _ A lA i �n Bir <br />PE Sc FReceived Check#/ Amount Date <br />Codes Info B Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />