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3 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS r <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ADDRESS <br />L <br />APN <br />LICENSE IC -57 ❑ C-61 ❑ D-09 -1 Other <br />3-7697 FOR INSPECTIONS LAPIRt5 1 YEAR FROM UATE ISSUED <br />CITY/ZIP' " <br />PARCEL SIZE ' LAND USE APPLICATION # <br />NUMBE <br />PHONE T�( — (✓✓ <br />CITY/STATE/ZIP La <br />90�PHONE G-� <br />CITY/STATE/ZIP!! �LA q---�'�L�✓ <br />PHONE y:N 44 <br />CITY/STATE/ZIP <br />EXPIRATION DA <br />)OMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural a 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 ❑ Geotechnical # of borings <br />❑ Out -Of -Service YVell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 41pumpReplacement Cl Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary 11 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter f 1 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 I Steel I l Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft Ll Neat Cement (94 Ib bag/5-10 gal water) 11 Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 11 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in El Christy Box ❑ Stove Pipe <br />Y <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,COMPENS,4tiIGN LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARTMENT USE ONLY <br />Date <br />_ Date <br />Date <br />Date - <br />- PLEASE CALL (209) <br />4_ DATE T <br />Area lqq Employee ID# <br />C] PECIAL Well Permit <br />CI WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Chec Amount Date Permit/ Invoice # Well ID# <br />Code Info B ash Remitted Service Request # <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />T <br />m <br />D <br />0 <br />v <br />X <br />m <br />N <br />