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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 IN-SQECT,IOONS— EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRE! <br />CONTRACTOR <br />CONTRACTOR P <br />-/AQ 11\1WAW��1'Af/Al='ijCf1t,1I/1=48ir•]►�.%����I. <br />SUBCONTRACTOR <br />U <br />LONE 4 -LL �f `yI • 1 7 W <br />?Ya-I�JCIA g5537cp f <br />-IONE /'/-1 'FIJI 3ZIV <br />PHONE <br />SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP ^' <br />LICENSE P,/C-57 1-1 C-61 I I D-09 F, Other NUMBER9Ua— EXPIRATION DATE /� 1111 q <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I 1 Arsenic (4393) <br />NTENDED USE U Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Ll 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 1 Other <br />❑ Monitoring Well(s) # of wells I I Soil Boring(s) # of borings 11 Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />l New PumD 'Sel5UmD Replacement 1.1 Pumo Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1.1 Push Point G Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom 1 Gravel Pack/Gravel Size in diameter <br />Ll Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water) 11 Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped I ] Free Fall ❑ Other n Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />1.1 Concrete Pedestal Ll 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 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 />WORKER,%WMPENSATION LAWS. <br />SIGNED <br />Z <br />W <br />2 <br />Q <br />CL <br />EP RTMENT USE ONLY <br />Application Accepted By Date ! �L <br />Grout Inspection By Date <br />Pump inspection By �� / Date cu ia <br />Soil Boring Inspection By Date <br />COMMENTS <br />- PLEASE CALL (209) <br />DATE <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />to <br />Area Employee ID#~ <br />f_I •SPECIALWeII Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Permit/ <br />Co Info B Cash Remitted Date Service Reguest # Invoice # Well ID# <br />45!7 i <br />EHD 43-06 8i01/16 WELL /PUMP PERMIT <br />