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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT,_,CALL <br />JOB ADDRESS N C_ <br />CROSS STREET 1 APN <br />ul <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS�(� <br />SUBCONTRACTOR <br />SUBCONTRACTOR <br />ADDRESS <br />LICENSE , C-57 ❑ C-61 <br />❑ D-09 ❑ Other <br />9) 953-fb9f FOR INSPECTIONS <br />n CITY/ZIP <br />L, 010 -, V PARCEL SIZE �� <br />NUMBER <br />CITY/STATE/ZIP <br />CITY/STATE/ZIP <br />VlKt, "I TEAR FROM UATE 155UED <br />PHONE <br />EXPIRATION DATE <br />)OMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Ulbron ochloropropane (43UZ) ❑Arsenic (43UJ) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water 8ystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) E] Geotechnical # of borings <br />El Out -Of -Service e E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />[:]New Pum um Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION 11 <br />Drilling Method El Mud Rotary ❑Air Rotary []Auger E] Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />F] Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑Bentonite (20% solids) ❑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 ❑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 />WGRKLRS GC)MoPENSATiON LAWS, <br />7MNIMY 4 OURA VANCENOTICE REQUIRED Fy RIINSRF_-CTION�S - PLEASE CALL (209)�766SIGNED � / /_1,�1' !/'('' 1� _i TITL3� G1 /lL�l//L ��t'1 1 DATE <br />C / 1 <br />EP RTMENT U E ONLY <br />Application Accepted By Date <br />IF V <br />_y Grout Inspection By Date <br />"tf Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COIvlfviEN T S <br />El <br />T <br />m <br />m <br />D <br />v <br />0 <br />m <br />m <br />Cn <br />ur <br />Area--7,-/'?.fEmployee ID#rr�r fo <br />❑ PE IAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Co Info B Cash Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />