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.,% 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 C <br />CALL (209) <br />/ v 209 95533--7697 FOR INSPECTIONS XPIRES 1 _Cl) <br />FR2m DATE ISSUED <br />JOB ADDRESS I [7 3 • /�J 67"71 ag CITY/ZIP EA% ! <br />CROSS STREET tAanva-t�P APN /F 3/woT PARCEL SIZE ID LAND USE APPLICATION # <br />PHON O <br />CITY/STATE/ZIP 1' )q / / no <br />P NE <br />CITY/STATE/ZIP =:f-% <br />PHONE <br />CI /STATE/ZIP <br />i <br />EXPIRATION DATE <br />OWNER NAME f <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ESS <br />LICENSE ilC-57 ❑ C-61 ❑ D-09 1 Other <br />NUMBER <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE U Domestic/Private Vrrigation/Agricultural U Industria! U Water Quality Monitoring U Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification <br />❑ Other <br />r9F'pp�, _ <br />Cl Monitoring Well(s) # of wells t I Soil Boring # of borings s) Ll Geotechnical 7'�r/cN <br />❑ Out -Of -Service ell L1 Out -Of -Service Well Renewal Ci Cross -Connection Repair <br />FINew Pump Pum ❑ Replacement Pum air <br />vG C <br />1-1Re Raise Well Casing'VC <br />WELL CONSTRUCTION <br />Drilling Method U Mud Rotary 11 Air Rotary ❑ Auger Li Cable Tool Ll Push Point <br />MAY U 2U18 <br />11 Other <br />Proposed Well <br />Well Casing <br />Depth ft Excavation in diameter CI Open Bottom 1_1 Gravel Pack/Grave QAQU�.diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft HEALTH NMENT� <br />D <br />Diameter _ in Thickness/Gauge/ASTM Sched F1 Steel ❑ Plastic F1 Stainless Steel ❑ OtheEPARTMEN7 <br />Grout Seal <br />Depth ft I I Neat Cement (94 Ib bag/5-10 gal water) <br />❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) t Other <br />Grout Placement Method U Pumped ❑ Free Fall I I Other ❑ Retardant <br />/ Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor F Other <br />U Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in U 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 />WORKEAKCOMPENSATION LAWS. <br />SIGNED <br />DEPARTMENT USE ONL <br />Application Accepted By , Date <br />Grout Inspection By Date <br />Pump Inspection By *rsftDate l) <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area D Iql Employee ID# <br />Fl SPECIAL Well Permit <br />I I WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />m <br />D <br />O <br />O <br />m <br />m <br />Cn <br />Cn <br />PE SC Received he Amount Date <br />Codes Info B ash Remitted <br />Permit/ Invoice # Well ID# <br />Service Re uest # <br />G77 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />