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4VI <br />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 A^UDRESS � � CITY/ZIP LD11 q <br />G <br />CROS STREET rme <br />�u <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />APN1 6 1�' ✓ PARCEL SIZE "1- /"�AND USE APPLICATION # <br />C ) n � � Fes. 'f t —I !.Z i I ) irll (t Ct 1 ' �/I _ AIME <br />f- Hv <br />P <br />CITY/STATE/ZIP <br />SUBCONTRACTOR A A PHONE <br />SU13CONTR R ADDRESS C /STATE//ZIP <br />LICENSE C-57 ❑C 61 [I D-09 E] Other NUMBER ,l EXPIRATION DATE <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 C;ontact 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) # of borings ❑ Geotechnical # of borings <br />E] Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump Xump Replacement ❑ Pump Repair [:]Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method El 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 mix17 gal water <br />[-]Benton ite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑Driller E] Pump Contractor ❑ Other <br />El Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP "ubmersible❑Turbine ❑Other HP // Pump Set ft Standing Water Level ft <br />I HEREBY CErRTIFY 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 />MINIM UR'i*k C ICE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95$-7697 <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date <br />Date <br />Date fl r J 1 <br />Date <br />Area hi'� `I. Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />W <br />rn <br />D <br />v <br />0 <br />X <br />m <br />w <br />N <br />PE SC Receivedhe <br />Codes Info B ash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />s <br />�? / C C <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />