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WELL/PUMP PERMIT <br />N <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 OR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/Z41 3 <br />CROSS STREET APN D '70d hARCEL SIZE LND USE APPLICATION # <br />OWNER NAME A PHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTORPHONE <br />CONTRACTOR ADDRESS t A N CITY/STATE/ZIP H <br />SUBCONTRACTOR �/ 1 PHONE rI <br />SUBCONTRACT?R ADDRESS IF CI /STATE/ZIP f - <br />LICENSE -57 ❑ C-61 ❑ D-09 El Other NUMBER EXPIRATION DATE <br />14 <br />DOMESTIC ELL 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 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 El Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION I <br />Drilling M od ❑Mud Rotary ❑Air Rotary ❑Auger Cable Tool ❑Push Point ❑ Ot r <br />Proposed Wel Depth ft Excavation in diameter en Bottom ❑ vel Pack/Gravel a in diameter <br />onductor Casing in diameter / Con ctor Casing Depth ft <br />Well Casing Diam r in Thickness/ uge/ASTM Sched E] Steel Plastic ❑Star ess Steel ❑Ot <br />Grout Seal Depth ft ❑ Neat ment (94 /b bagl5-1 I water) d Cement sac W7 gal water <br />E] Bentonite %solids) ❑Other <br />Grout Placement Method ❑ Pump ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL In [led ByIller ❑ �Contr for ❑ Other \ <br />❑C to Pedesta imensions: Width�ft—6epgth ft Thic"I F] Ch-nsty Bo E] Stove Pipe <br />PUMP it 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,CQMPENSATION LAWS. <br />SIGNED <br />REQUIRED <br />y <br />' EPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By A Date <br />Pump Inspection By y a -"'t s , Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />PLEASE CALL (209) 953-769 <br />DATE I D , <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />vi <br />i— <br />Z <br />w <br />F- <br />a�. <br />w <br />0 <br />x <br />Area Employee ID# t75; L11ft� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Permit/ <br />Codes Info B Cash Remitted, - ate Service Request # Invoice # Well ID# <br />V — G,LF�9 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />