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` WELL/PUMP PERMIT 1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 299 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRES U V4 <br />I, CITY/ZIP <br />CROSS STREET APN ^ ,/ �V - PARCEL SIZE r LAND US APPLICATION <br />OWNER NAME V b)"PHON� <br />OWNER ADDRESS _ 11 CITY/STATE/ZI Y U/_ �� , I. �A <br />CONTRACTOR PHONk:�JLn--" L�l L" <br />CONTRACTOR ADDRES CITY/STATE/ZIP c7 `"f�1-"� <br />SUBCONTRACTOR PHO <br />SUBCONTRACT R ADDRESS ITY/STATE/ZIP <br />LICENSE C-57 El C-61 F1 D-09 ❑Other NUMBER 6 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE 14 Domestic/Private ❑Irrigation/Agricultural ❑Industrial E] Water Quality Monitoring El Soil Sampling/Characterization <br />❑ ublic 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 E] Other <br />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) E] Geotechnical # of borings <br />❑Out-Of-Serviceell ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />E]New Pump tPump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />F] 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 /b 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 E] Pump Contractor ❑ Other <br />F] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP USubmersible ❑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 />Fig W07M <br />Ilk, I <br />lid\■■■■■■■ ■■�■■ ■'1■■■■■■■■■I■■■■ <br />■■■■■■■■■E�7■ mil■■■Ill.��i'►i ■■■■I■■■■ <br />■■■■■■■■i�■X11`iii■1f'�i�lt'i'�i��J■■■���J■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■■■■■■■■■■■■■■■■■■ <br />1ARTMENT USE ONLY <br />Application Accepted By�. �>�f — Date' <br />Grout Inspection _ r Date <br />Pump Insp <br />_ - <br />. �'w Df <br />Soil Boring Inspection By DCOMMENTS <br />ate <br />PLEASE CALL (209) <br />DATE <br />T <br />m <br />v <br />0 <br />m <br />m <br />Area 4 G Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Reco"Ved <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date <br />Codes Info By Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 8/01/11 WELL /PUMP PERMIT <br />