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n <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE F'ERMII <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS A <br />CONTRACTOR <br />r <br />CONTRACTOR ADDRESS i <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />UALL ILUyI yb3-/by/ FOR INSPECTIONS-AI'IKtb 1 YEAR FROM DATE ISSUED <br />CITYIZ^IIPr Z,4 /f � [ f`/ `F �_/— <br />A�PyN, O U lP 00 PARCEL SIZE V LAND USE AAjP�PLICATIO # <br />PHONEan— n— �l.6 <br />CITY/STATE/ZIP/P<r <br />iag <br />, <br />is PHONE <br />CITY/STATE/ZIP <br />Al PHONE <br />C /STATE/ZIP <br />LICENSE X P-57 ❑ C-61 ❑ D-09 [I Other NUMBER EXPIRATION DATE J <br />DOMESTIC WELL PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE _ Domestic/Private ❑ Irrigation/Agricultural I I Industrial I1 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ 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 ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out-Of-Servic ell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 1 1 Auger ❑ Cable Tool CI Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter LI 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 H Steel F1Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft I I Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Il Pumped ❑ Free Fall I Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller LI Pump Contractor F1 Other <br />Ly Concrete Pedestal Ll Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP I Submersible[] Turbine 11 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 />Y <br />SIGNED <br />T <br />DEPARTMENT US/QE� ONLY <br />Application Accepted By whkDate <br />Grout Inspection By Date <br />Pump Inspection By i Date (9 7' J <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />F1 WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />Sc Received hec <br />info B aso <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />