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1- <br />WELL/PUMP <br />WELL/PUMP PERMIT P <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,�OR INSPECTIONS E5PIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREEFs <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTyRR ADDRESS <br />�D. <br />APNIfY2% UJ'V <br />'- <br />LICENSE It1 C-57 I_I C-61 ❑ D-09 I I Other <br />CITY/ZIP <br />/PARCEL SIZE a f±__`LAND USE APPLICATION # Q <br />LujS PHONE2_r1A1_?-*q —�u-iU <br />ryd <br />_ CITY/STATE/ZIP 7��t/7� ' <br />PHONE2_ / " Jam/ CJ <br />CITY/STATE/ZIP <br />PHONE <br />CITiY/STATE/ZIP <br />NUMBER <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: i 'General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) I Arsenic (4393) <br />INTENDED USE ry Domestic/Private ❑ Irrigation/Agricultural -1 Industrial ❑ Water Quality Monitoring I 1 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 />F1Monitoring Wells) # of wells Li Soil Boring # of borings s) F1 Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casin CFS <br />WELL CONSTRUCTION APR <br />R q <br />Drilling Method IJ Rotary [IAir Rotary LI Auger ❑ Cable Tool 11Push Point F1Other ` 7 2� <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom ❑ Gravel Pack in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft HEAL Hr pDNMEN' . v �� <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑I Plastic ❑ Stainless Steel 91NIk4 r___ <br />Grout Seal Depth ft I 1 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumoed ❑ Free Fall ❑ Other _ 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller [I Pump Contractor I I Other <br />❑ Concrete Pedestal F1 Dimensions: Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ILSubmersible ❑ Turbine ❑ Other HPC 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 />MMIMUM A4 HOUMM)N NCENOTICE REQUIRED FOR INS IONS - PLEASE CALL (209) 9P3i-769,7 , — <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />TITLE <br />D ARTMENT USE PNLY <br />Date <br />Date <br />Date <br />Date <br />DATE <br />T <br />m <br />D <br />v <br />0 <br />m <br />m <br />N <br />Area -lam Employee ID#ma <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />PE SC Received hec Amount Permit/ <br />Copies Info B as Remitted at Service Request # Invoice # Well ID# <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />