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+«. V <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 GALL ZUy U0J-/bU[ FOR INSPECTIONS tArlKtJ I TEAK I-KUlM UAIt I/b5UtU <br />k ii— <br />JOB ADDRESS CITYY//JZIP�L ru � <br />CROSS STREETno APN r U a P RC L SIZES HCl I LAND USE APPLICATION # <br />OWNER NAME H,,l C: k J(-'10 ONE2Li Z29 <br />OWNER ADDRESS W CITY/STATE/ZIP <br />Ch 95:Xc� <br />CONTRACTOR PHONE E 2Xq— Q 1 ✓ % 75P_J %) <br />CONTRACTOR ADDRESS �lCITY/STATE/ZIP � <br />SUBCONTRACTOR PHONE 114 <br />SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP <br />LICENSE -57 F1C-61[ID-09 [IOther NUMBER ml&EXPIRATION DATE �✓ <br />)OMESTIC WELLS MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE Domestic/Private ❑Irrigation/Agricultural [-]Industrial E] Water Quality Monitoring ❑Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well []Well Alteration/Modification ❑ Other <br />❑Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />❑Out-Of-ServiceyVell E] Out -Of -Service Well Renewal []Cross -Connection Repair <br />F1 New Pump ump Replacement 17 Pump Repair F] Raise Well Casinq <br />Drilling Method ❑ Mud Rotary []Air Rotary ❑Auger ❑ Cable Tool ❑ 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 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 ❑ Pump Contractor ❑ Other <br />F-1 Concrete Pedestal Epimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HPPump 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 />IMUM 24 On"F'��ME <br />REQUIRED FOR NSPEC NS - PLEASE CALL (209) -7 97 <br />SIGNED TITLE DATEM, 17 <br />E ARTMENT U E ONLY <br />Application Accepted By --� Date <br />Grout Inspection By Date <br />Pump Inspection By i Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID#a� <br />❑ PECIAL Well Permit <br />WAIVER PeCeived <br />Constructed Well Depth ft <br />T <br />1 <br />m <br />D <br />v <br />v <br />m <br />m <br />in <br />Cn <br />PE SC Received Check#/ Amount <br />Codes Info B Cash emitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />