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• 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 09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ECITY/ZIP <br />CROSS STREET APN���� �%' V PARCEL SIZE LAND USE APPLICATION <br />OWNER NAME PHONE - <br />jq1_qT7�a <br />:Wfj� q� <br />OWNER ADDRESS N/ TA E/ZIP <br />CONTRACTOR PHONE / %� <br />CONTRACTOR ADDRESS / CITY/STATE/ZIP <br />/ p <br />SUBCONTRACTOR /x 4 PHONE �l <br />LICENSE <br />ADDRESS <br />57 ❑ C-61 <br />❑ D-09 ❑ Other <br />NUMBER <br />C <br />EXPIRATION <br />)OMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />of <br />NTENDED USEomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El 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 />El Monitoring Well(s) # of wells [:]Soil Boring # of borings s) ❑Geotechnical # of borings <br />El Out -Of -Service ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump ump Replacement ump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] 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 E] 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 />E] Concrete Pedestal EDimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CER FY 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 />I IMUM 24 HO <br />F�t1V N_E NOTICE REQUIRED FINSPECMS -- PLEASE CALL (209)M7 11 <br />SIGNED _-*AW'//V / TITLEO PA �"k DATE '� <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EP RTMENT <br />E N L Y <br />Date 7/ <br />Date <br />Date ZV <br />Date <br />Area Employee <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received hec Amount Permit/ <br />Co s Info B ash emitted Date Service Request # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Cn <br />