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X <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERM/IITT� CALL <br />(2 99) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS L,i <br />CITY/ZIP <br />CROSS STREET APN <br />-' PARCEL SIZE Z 1 LAND USE APPLICATION # <br />OWNER NAME <br />PHONE <br />0 ezyCITY/STATE/ZIP <br />OWNER ADDRESS 1 <br />l J <br />CONTRACTOR WATM11166 <br />HO�N�E(%� <br />CONTRACTOR ADDRESS bA! !! lLC'1�c. <br />/` { yj( CITY/STATE/ZIP 1 � " ( 7 /L� <br />SUBCONTRACTOR AI <br />PHONE 44 <br />SUBCONTRACT R ADDRESS <br />CI Yy/STA�TE//ZIIP/J <br />LICENSE C-57 F1 C-61 1i D-09 I Other <br />NUMBER L v Ur �/' EXPIRATION DATE <br />DOMESTIC 4ELL SAMPLING: i I General Mineral/Coliform Bacteria (4391) I Dibromochloropropane (4392) I Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural -1 Industrial [ l Water Quality Monitoring ❑ Soil Sampling/Characterization <br />ublic Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well <br />❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells <br />❑ Soil Boring(s) # of borings 11 Geotechnical # of borings <br />❑ Out -Of -Service ll <br />❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump V Pump Replacement <br />❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool LI Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom [I Gravel Pack/Gravel Size in diameter <br />Li Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched r I Steel 11Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) 11 Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped LI Free Fall ❑ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal I_)Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CER FY 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/CQMPENSATION LAWS. <br />INVtbe <br />24�ONTICEREQUIRED FO IN PEEO�\SIGNED p � <br />TITLEV'14I <br />EP�RTMENT USE ONLY <br />Application Accepted ByADate <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />-LPLEASE CALL (209)) <br />r� \ DATE L <br />Area Employee IDA/, ✓( V�7 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received h Amount Permit/ <br />Cods Info B Cash Remitted Date Servi a Re uest # Invoice # Well ID# <br />S g <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br /><3 <br />Z <br />