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1 r WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUIV-KEFUNDABLE PERMIT JOB ADDRESS 40 CROSS STREET OWNER NAME �(L OWNER ADDRESS T CONTRACTOR a CONTRACTOR ADDRESS `' SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE )(C-57 ❑ C-61 Cl D-09 J Other CALL ZUy U53 -14U1 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED CITY/ZIP //y / �� O N ( V� PARCEL SIZE LAND USE APPLICATION # "—T— PHONE W I I JC CITY/STATE/ZIP I1�' In/nl tom o Amt .--_-_ I?nom,►./�O).2 Y, CITY/STATE/ZIP(] V(/IA-1 V% PHONE CI Y/STATE/ZIP NUMBER EXPIRATION DATE I DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i I Arsenic (4393) INTENDED USE Domestic/Private 11 Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterization Li Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings ❑ Out -Of -Service Well a Out -Of -Service Well Renewal LI Cross -Connection Repair V New Pump ❑ Pumo Replacement ❑ Pump Reoair ❑ Raise Well Casino Drilling Method ❑ Mud Rotary ❑ Air Rotary 11 Auger a Cable Tool [_I Push Point [.I Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom LI Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) Ll Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor [-1 Other ❑ Concrete Pedestal I IDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP U Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENTNNI ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERSENSATION LAWS. M 2 O C TCE REQUIRED F I WMW - PLEASE CALL (209) 53- 6 7 SIGNED / TITLE DATE ' D� ARTMENT USE ONLY Application Accepted By Date z' ll Grout Inspection ByDate Pump Inspection By Date ti Soil Boring Inspection By Date r:rIKAMFNTS Area Employefl& IJ SPECIAL Well Permit ❑ WAIVER. Received Constructed Well Depth ft PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# Cocles Info By Cash Remitted Service Re uest # EHD 43-06 8/01/16 WELL /PUMP PERMIT T m D 0 0 m En