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� <br />• WELL/PUMP PERMIT V <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 'I YEAR FROM DATE ISSUED <br />JOB ADDRESSIts c p ^ n W 4 CITY/ZIP <br />CROSS STREET APN O� S PARCEL SIZE �' u 5 LAND USE APPLICATION # <br />Caw -AOWNER NAME N r ' G1 ti (.1 -7 -1 b C i 10, r i) /T t / PHONE <br />OWNER ADDRESS ---+ 2,2 TP-/ CITY/STATE/ZIP �� Y� 1 lJ 1 ►�lY In <br />CONTRACTOR ^/ PHONE 2���) <br />CONTRACTOR ADDRESS I�� CITY/STATE/ZIP �✓C"I�ZZ.1 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 1P-57 61 ❑ D 09 ❑Other NUMBER A2A[(V EXPIRATION DATE i <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE omestic/Private ❑ Irrigation/Agricultural [:]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 E] Other <br />❑ Monitoring Well(s) #of wells ❑# of borings Soil ❑Geotechnical # of borings <br />❑Out -Of -Service We I ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pum Pum Replacement ❑ Pump Repair [-]Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ 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 ❑Steel ❑Plastic El 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 ❑Pump Contractor ❑ Other <br />❑Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box [-]StovePipe <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. 1 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 />E <br />EPARTMENT USE ONLY <br />Application Accepted By XJvl� Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />0 <br />T <br />✓6 <br />rqs-. ib <br />Area 3 Employee ID# Ah ✓Y) f' Gl <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc Receivedec <br />Info <br />- Amount <br />ash Remitted <br />Permit/ <br />D to Service Request # Invoice # Well ID# <br />p s v <br />3 i <br />iJ P063*7 . <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />