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• I 'WWELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABL PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />/I IlAd <br />(� <br />CROSS STREET APN v PARCEL SIZE�V/ y/� _LAND SE PPL CATION # <br />OWNER NAME+so) �� �Q )< / HONE � I <br />OWNER ADDRESS CITY/STATE IZIP <br />Cgs <br />CONTRACTORS (/�J j�� / LHONE��(�'/ f�J may! V <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />CITY/STATE/ZIP Qbz- J4 d?09,/S <br />PHONE <br />SUBCONTRAcg ADDRESS CI STATE/ZIIP_ <br />LICENSE 57 ❑ C-61 ❑ D-09 ❑Other NUMBER lX EXPIRATION DATE <br />DOMESTIC 4ELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water Syste <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 />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />E] Out -Of -Service II E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump Pump 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 E] 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 ❑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) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal ❑)imensions: Width ft Length ft Thick in ❑ChristyBox ❑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 />SIGNED <br />DEPARTMENT USE ONLY <br />Application Accepted By Date /15� /1 -7 <br />Grout Inspection By Date <br />Pump Inspection By J Date i 2 <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />1 <br />m <br />a <br />O <br />0 <br />m <br />m <br />cn <br />V7 <br />Area Employee ID#Z&-�h <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received aAmount ate Permit/ Invoice # Well ID# <br />Codes Info B ash Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />