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t <br />I. WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONfyIENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />�'C-)0 <br />NON-REFUNDABLE PERMIT CAL 9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />If <br />CROSS STREET S �n l� t' qp I �1 3 a y C PARCEL SIZE LAND USE APPLICATIONAIA <br /># <br />OWNER NAME P ONE <br />OWNER ADDRESSII '' CITY/STATE/ZIP p <br />CONTRACTOR (1V1� �1/lil PHnNF <br />CONTRACTOR ADDRESS 4i4 L --LI (AJ I I (J(,�F\ CITY/STATE/ZIP (.jm ( IrL <br />SUBCONTRACTOR 1A PHONE <br />SUBCONTRACTOR ADDRESS C TY STATE/ZIP <br />LICENSE 16 C-57 El C-61 [I D-09 E] Other NUMBER EXPIRATION DATE _ <br />DOMESTIC EL S MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural []Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name (;ontact Name or Phone um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) # of borings # of borings <br />[:]Geotechnical <br />❑Out -Of -Service W II ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />E] New Pum Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <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 F] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />F-1 Bentonite (20% solids) F-1 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑Driller F-1 Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP %tsubmersible[:] ❑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. 1 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 />I <br />E <br />a E,PARTMENT USE ONLY <br />Application Accepted By�� � Date 9 1 <br />Grout Inspection By Date <br />Pump Inspection By AW11 Date / <br />Soil Boring Inspection By Date _ <br />COMMENTS <br />Area I / / � Employee ID# Ahmed <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received <br />Codes Info By <br />Check#/ <br />ash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />