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WELL/PUMP PERMIT <br />ySAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209953-7697 FOR INSPECTIONS tAFIKt, 'I YEAR FROM DATE ISSUED <br />% <br />JOB ADDRESS `'C- V" t f t CITY/ZIPVA . 6~ <br />CROSS STREET \n PN / 7 9 ¢ j ao �/ PARCEL SIZE S LAND USE APPLICATION # <br />OWNER NAME Y \ PHONE WT (� <br />�j _-J <br />OWNER ADDRESS VL f CITY/STATE/ZIP 2-� <br />j <br />CONTRACTOR PHONE / V <br />CONTRACTOR ADDRESS9d CITY/STATE/ZIPt4n v <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP <br />LICENSE C-57 61 [_1 D-09 ❑Other NUMBER EXPIRATION DATE <br />rinMFRTir WFI I RAMpi mr- I—IC;Pneral Minaral/Cnlifnrm RactPria (43gl I F-1Dihromnchloroor0oane (4392) FlArsenic (4393) <br />NTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: a er System Name on ac ame or one Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑Geotechnical <br />E] Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump 'pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /># of borings <br />Drilling Method ud Rotary El Air Rotary Auger ❑Cable Tool ush Point ❑ Other <br />Proposed Well Dept ft Excava ' n in diameter Open Bottom ❑Gravel Pack/ avel Size in diameter <br />❑ Con for Casing in dia eter / Conductor Casing Dep ft <br />Well Casing Diameter in Thickness/Gauge/A M Sched ❑ St 1 ❑ Plastic ❑ Stainless Steel Other <br />Grout Seal Depth ft ❑ Neat Cement 4 Ib bag/5-10 gal water) Sand Cement ack mix/7 gal water <br />❑ Bentonite (20%so' s) E] Other <br />Grout Placement Method ❑Pumped vee Fall E] Other E] Retardant /A elevator (name) <br />PEDESTAL Installed-Qy El Driller El Pump Contr or ❑ Other <br />E] Concrete `Pedestal dimensions: Width ft Length Thick in hristy Box ❑S Pipe <br />PUMP 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 COMPENSATION LAWS. <br />TnA� <br />D CE NOTICE REQUIRED FMiTTA'S <br />- PLEASE CALL (209) 953ti <br />6971 <br />SIGNED % TITLE W DATE ?— / <br />Application Accepted By <br />EPARTMENT(^,USE ONLY <br />Date <br />Grout Inspection Bynn <br />Pump Inspection By <br />7 bbc /� <br />/I/I�I - hne -1 <br />TAT <br />Date <br />Date W-1,711;? <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />4 <br />T <br />1 <br />m <br />D <br />v <br />v <br />m <br />rn <br />ur <br />ur <br />Area I Z / Cl Employee ID# Ahr4,,z,l <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />Sc ReceivedChec <br />Info B ash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />