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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 />NUN-KEFUNDABLE VERMII <br />JOB ADDRESS 2-1 1 <br />CROSS STREET YV�%�'�i <br />OWNARW _k <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE -57 <br />rel 010W011' , AM, <br />NFA .IIS <br />C-61 ❑ D-09 ❑ Other <br />7 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br />CITY/ZIP <br />PARCEL SIZE LAND USE APPLICATION # <br />a PHONE <br />CITY/STATE/ZIP JL— <br />PHONE <br />CITY/STATE/ZIP / <br />405215 <br />PHONE <br />C TY/STATEIZIP l <br />NUMBER 1 LV 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 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() E] Geotechnical s # of borings # of borings <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump N115-ump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑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 E] Driller ❑Pump Contractor ❑ Other <br />E] 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 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 />c <br />DEPARTMENT US ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />rn <br />I <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Area Employee iD#� 0 <br />❑ SPECIAL ell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info By ash Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />