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.�A <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />(:ALL 1Uy <br />UbJ-/by! FOR INSPECTIONS <br />tXVIKtb I YEAR FROM UATE ISSUED <br />JOB AD RES <br />CITY/ZIP <br />/✓/ �7 <br />L� <br />CROSS STREET <br />APN-DID <br />P CEL SIZE/ {� <br />LAND USE APPLICATIO # <br />a <br />- <br />OWNER NAME _ <br />PHONE <br />OWNER ADDRESS 99W <br />CITY/STATE/ZIP <br />C <br />CONTRACTOR <br />PHONE3— <br />CONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACT R ADDRESS <br />LICENSE 7-57 ❑ C-61 <br />❑ D-09 <br />CI Other <br />C6ty/STAAATTEE//ZI/P <br />NUMBER (1 +` �L� <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE A <br />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 Numb AA <br />TYPE OF WORK ❑ New Well ❑ Replacement Well CI Well Alteration/Modification ❑ Other rt <br />bori <br />[IMonitoring Well(s) # of wells f_1 Soil Boring # of borings s) Li# of Geotechnical �$� <br />Li Out -Of -Service ell _1 Out -Of -Service Well Renewal 11 Cross -Connection Repair APR R Z 6 Z018 <br />❑ New Pump 4 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION H ENVIRpNME tJUNn, <br />Drilling Method ❑ Mud Rotary 11 Air Rotary Li Auger Ll Cable Tool 1 I Push Point 11 Other EALTWrz IA A1Tq�u7� <br />Proposed Well Depth ft Excavation in diameter [ I Open Bottom [ I Gravel Pack/Gravel Size IIIIn�fameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic F1 Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ 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 ❑ Pumped ❑ Free Fall 1-1 Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑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 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 COMPENSA ION LAWS. <br />NNIMUM-RHQ.IJR AQVANCE WO.TICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9§3-7697„ <br />SIGNED <br />TITLk_ sb 0 i0A!_t h ( A- DATE A <br />DEPARTMENT U E 9NLY <br />qjApplication Accepted By Date Area Employee ID# <br />Grout Inspection By Date ❑ PECIAL Well Permit <br />Pump Inspection By J Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />PE SC Received Ch Amount Date Permit/ Invoice # Well ID# <br />o s Info ash emitted Service Request # <br />Z,-ql2,&IIY 0003bicd <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />T <br />m <br />D <br />v <br />0 <br />m <br />m <br />