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I 7, C V L <br />WELL/PUMP PERMIT <br />SAN JOAQUIN 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 r I CITY/ZIP <br />CROSS STREET N Y� (1 (�•2-PARCELSIZE 2, 3 � LAND USE APPLICATION # <br />OWNER NAMEMeYR L✓ PHONE <br />OWNER <br />OWNER ADDRESS 5 CITY/STATE/ZIP <br />CONTRACTOR -`''J � PHONE [,�(/"� 3J <br />CONTRACTOR ADDRESS 7t/ CITY/STATE/ZIP <br />SUBCONTRACTOR A PHONE <br />SUBCONTRAVC <br />R ADDRESS TY/STATE/ZIP <br />LICENSE f-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER4kvu EXPIRATION DATE V� <br />DOMESTIC WEL S MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Uontact Name or Phone 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 # of borings <br />❑Out-Of-ServiceII El Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />ElNew Pump Vpump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method El Mud Rotary E] 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 />F1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic El Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib 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 ❑ Pump Contractor ❑ Other <br />❑Concrete Pedestal dimensions: Width ft Length ft Thick in [:]ChristyBox ❑Stove Pipe <br />42 <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 />(!M4MR D�/V1%A�%NCfEINOTICE REQUIRED FO INSPE TIONS/ - PLEASE CALL (209) 76 7% <br />SIGNEDY II/, l i) TITLE 1114 DATE �! / - V�/ <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />D ARTMENT USE ONLY <br />Date <br />-Date <br />Date ( - <br />Date <br />Area � ( l 9 Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received CChec Amount Date Permit/ Invoice # Well ID# <br />Codes Info Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />