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WELL/PUMP PERMIT Q <br />SAN AAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CAJL 209 953-7697 FOR INSPECTIONS 04EXPIRES 1 YEAR FROM DATE ISSUED <br />r <br />JOB ADDRESS VA CITY/ZIP <br />AA A All 14/ <br />CROSS STREET APN D 7 1 33 ` 06 PARCEL SIZE 0' - /LAND USE APPLICATION # <br />OWNER NAMEY(JA6e r 1 h J 6! A C Pit PHONE f-1) <br />OWNER ADDRESS CITY/STATE/ZIP /./ <br />CONTRACTOR \ PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP ( \/(�•i�,r(�"' `-� <br />SUBCONTRACTORPHONE <br />SUBCONTRACT ADDRESS CI Y/ TATE/ZIP <br />LICENSE C-57 I I C-61 11D-09 11 Other NUMBER EXPIRATION DATE <br />DOMESTIC WELLAMPLING: i General Mineral/Coliform Bacteria (4391), Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 11 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 CI Geotechnical # of borings <br />❑ Out-Of-Service�V�II 11 Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />Li New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger IJ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter f_I Open Bottom El Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched N Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft I I Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method I 1 Pumped ❑ Free Fall n Other Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller I I Pump Contractor I1 Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in 11 Christy Box ❑ Stove Pipe <br />IPUMP b Submersible Turbine ❑ Other HP / 7d Pump Set ft Standing Water Level ft <br />I HEREBY CERYIFY 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 />WORKERSi6,OMPENSATION LAWS. <br />SIGNED <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />DEPARTMENT USE ONLY / <br />Application Accepted By Date 5 3 " D Area / Employee ID# " <br />Grout Inspection By Date 4 ❑ SPECIAL Well Permit <br />Pump Inspection By w Date 12-111 X 1_1 WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received h Amount Permit/ <br />Info B Cash Remitted 19 ate Service Request # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />