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WELL/PUMP PERMIT + / i <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 0'5�2 CITY/ZIP E <br />CROSS STREEETIAO UR APN IC) ) I PARCEL SIZE O 1 I LAND USE APPLICATION # <br />L, it <br />OWNER NAME PHONE/10 1/1 /��/�//•� F�O� (r 5q I. ) <br />OWNER ADDRESS O CITY/STATE/ZIP 4=�{�M2r� l �i <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS (/ LTJ CITY/STATE/ZIP ' VY t ( L <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP Q <br />LICENSE 11C-57 F1 C-61 [ID -09 I I Other NUMBER EXPIRATION DATE — 1 <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 11 Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I I Cross -Connection Repair <br />❑ New Pump YumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ 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 11 Steel ❑ Plastic Cl Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal wate/) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) IJ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I I Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine I I Other HPPump 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 WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATIO AWS. <br />MINI ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 951-7697 <br />SIGNED TITLE DATE 7 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 3' � 3 `► t <br />Grout Inspection By Date <br />Pump Inspection By Date 0 <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />0 <br />Area ' �ry Employee ID# J , h m /' e� <br />U SPECIAL Well Permit <br />Ll WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received he <br />Info Cash <br />Amount <br />Remitted <br />Date Permitt Invoice # Well ID# <br />Service Request # <br />3s I <br />C -6_20S <br />3 <br />s 3 -2i-W � <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />