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WELL/PUMP PERMIT <br />SAWJOACIUIN -OUNTY 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 <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />LICENSE <br />ADDRESS _ <br />57 a C-61 <br />_LIq <br />_12,O <br />953f.7697 FOR INSPECTIONS <br />tXPIKtS 9 YEAR FROM IJTE ISSUED <br />a- IJ P 0 -S <br />CITY/ZIP <br />/_ <br />�V <br />N <br />PAymul <br />RCEL SIZE�LAND <br />USE APPLICATION # <br />7Fiigr 1� <br />PHONEqr <br />ITY/STATE/ZIP <br />P ONE <br />J <br />CITY/STATE/ZIP <br />PHONE � <br />11 <br />C ICY/STAT E/ZI P <br />- <br />❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION DATES L4, <br />DOMESTIC WELL PLING: _i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I I Arsenic (4393) <br />INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial I 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) If of borings ❑ Geotechnical # of borings <br />Ll Out-Of-ServiceII ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump U Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point D Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) LI Other <br />Grout Placement Method LI Pumped ❑ Free Fall ❑ Other 1-1 Retardant / Accelerator (name) <br />PEDESTAL Installed By IJ Driller ❑ Pump Contractor I I Other <br />I I Concrete Pedestal ]Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />No <br />PUMP 1, 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 COMPENSATION LAWS. <br />SIGNED <br />PO I IMUM 24 HOUJ;�ADVANCE NOTICE REQUIRED FOR INSPECJIONS -PLEASE CALL (209) 953f769j — <br />TITA <br />PA TMENT U E ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date (9 Is IAN <br />Soil Boring Inspection By Date <br />COMMENTS <br />DATE <br />4 <br />Area ` Employee ID#. <br />E SPECIAL Well Permit <br />El WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />D <br />rn0 <br />0 <br />rn <br />N <br />cn <br />PE SC Received <br />PQ*s Info B <br />(Cfiec_W Amount Date Permit/ Invoice # Well ID# <br />s Remitted Service Request # <br />a- IJ P 0 -S <br />EHD 43-06 8/01/16 <br />WELL /PUMP PERMIT <br />