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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-KEFUNDAB <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />ERMIT <br />CONTRACTOR ITISr <br />CONTRACTOR ADDRESS G)L4= <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE 111C-57 ❑ C-61 <br />L;ALL 1 5J -/by/ FOR INSPECTIONS A tAl'IKtS 'I YEAR ROM UATE ISSUED <br />R100 W CITY/ZIP affftww (A W) <br />/APN I �_U � ) PARCEL SIZE LAND USE APPLICATION # <br />i <br />Q\ nod5 PetPHONE <br />10 CITY/STATE/ZIP fes` <br />If <br />P NE <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION DATE / ' <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) I Dibromochloropropane (4392) I_' Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private X Irrigation/Agricultural ❑ Industrial [I Water Quality Monitoring LI 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 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />❑ New Pump X Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point LI Other <br />Proposed Well Depth ft Excavation in diameter I I 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 LI Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Ll Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By LI Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal Cl Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersibl 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 />IM/UM 4 10. AD A Ep NOTICE REQUIRED FO INSPE TIONS - PLEASE CALL (209) 9!751697 FJ�///�+/� <br />TITLE DATE la'ry�' <br />Application Accelated By <br />SC Received <br />Info By <br />9EPAFATMENT/iUSE ONLY <br />Date 2 - <br />`1 <br />Grout Inspection By <br />t <br />Date <br />Pump Inspection By <br />4 —I' <br />00'3t6i,-_3 <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area / `/ �� Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received <br />Info By <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />4 —I' <br />00'3t6i,-_3 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />