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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET APN O 0 T 0,51 U/1 PARCEL SIZE / Ij <br />, % 7 LAND USE APPLICATION <br />OWNER NAME �PHONEQM� <br />OWNER ADDRESS CITY/STATE/ZIP 5a1� <br />CONTRACTOR PHONE � <br />CONTRACTOR ADDRESS CITY/STATE/ZIP ) 0� QST S <br />SUBCONTRACTOR PHON <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />P/ <br />LICENSE -57 El C-61 E] D-09 ❑Other NUMBER EXPIRATION DATE JJ <br />DOMESTIC � ELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE ❑ Domestic/PrivateIrrigation/Agricultural []Industrial E]Water Quality Monitoring ElSoil Sampling/Characterization <br />F]Public Water Sys m <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification E] Other <br />El Monitoring Well(s) #of wells [:]Soil Boring # of borings s) ❑Geotechnical # of borings <br />El Out -Of -Service II E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />L]NewPump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] 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 ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑Driller E] Pump Contractor ❑ Other <br />E] 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 COMPENSATION LAWS. <br />Ml00(1jf134 HOUP ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76, 7, <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />IWA <br />c <br />DATE / <br />PARTMENTfUSE ONLY <br />Date I <br />Date <br />Date <br />Date <br />I NDN r �_/may <br />Area / �/ Employee ID# C Scr <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />1 <br />M <br />D <br />v <br />v <br />m <br />m <br />in <br />PE Sc ReceivedAmount <br />Codes Info <br />Date <br />ec ash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />Ti ZI 7 <br />w Pot <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />