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WELL/PUMP PERMIT <br />SAN .k.QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS , EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />11,"K [) I (LA <br />CITY/ZIP W(!/Uf <br />ufv -1 % J <br />CROSS STREET <br />APN U) 1 U s <br />PARCEL SIZE $' S <br />LAND USE APPLICATION # <br />OWNER NAME ' `n 4 <br />GI ' e r <br />PHONE <br />OWNER ADDRESS (� <br />U C le ✓':- to AL`% Q <br />CITY/STATE/ZIP <br />CONTRACTOR <br />�Q t <br />PHONE <br />CONTRACTOR ADDRESS(9119-0 <br />C! / ` W/� � <br />CITY/STATE/ZIP <br />�yj f� <br />I %// f - ( � 91 J <br />SUBCONTRACTOR <br />&PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 El C-61 <br />CIT�Y//STATE/%ZIP <br />[ID -09 [I Other NUMBER V tom(TE <br />EXPIRATION DATE / <br />DOMESTIC IWELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) <br />❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring [-]Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name (;ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑Out -Of -Service Well E] Out -Of -Service Well Renewal []Cross -Connection Repair <br />rl New PumD F-1 PumD Replacement VfPumD Repair F] Raise Well Casina <br />Drilling thod ❑Mud Rotary Air Rotary ❑Auger Cable Tool ❑Push Poin ❑ Other_ <br />Proposed II Depth Excavation in diameter ❑Open B om ❑Gravel Pack/Gravel Si in diameter <br />Conductor Casing in diameter / Con for Casing Depth ft <br />Well Casing meter in Thick ss/Gauge/ASTM Sched ❑Steel ❑Plas �E]StamlessSteel ❑Other <br />Grout Seal Dep ft at Cement (941b bag/5-10 g ater) ❑Snd Ce sack mix 7 gal water <br />❑ Benton a (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL nstalled By ❑ Driller Pump Con11 ctor ❑ et lamer <br />6oncrete Pedestal �imdl�sions: Width ft Leng rr ft ick in hristy Box CjStovePipe <br />PUMP Submersible❑Turbine ❑Other r V 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 />I IMUM 4H�O ADVVjA�NCE_ OTICE REQUIRED FORINSPECTIONS-PLEASE CALL (209) 9537 <br />SIGNED �ftA,� I" / (�(/v(I TITLE DATE <br />Application Accepted By <br />ARTMENT <br />� Date <br />USE ONLY <br />T" ^ t' <br />Grout Inspection By <br />Date <br />00 > 7 <br />Pump Inspection By <br />I Date <br />Ci <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area / Employee ID# C S ('c ! }' <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />PE SC Received Check#/ <br />Codes Info By ash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />00 > 7 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />