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1 / _ <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 n n CALL (209) 953-7697 EOR )NSPECTIONS / ExP)RES 1 YE69 FROM DATE ISSUED <br />JOB ADDRESS <br />%,fAWFr"MMF5L/JBAF1= <br />A9 <br />;r - � t ►� �� �� u�P <br />NAME <br />1 $7, ON IN <br />ADDRESSOWNER <br />OWNER ..4 <br />MIND�llL <br />CONTRACTI OR <br />CONTRACTOR ADDRESS <br />".)Flom <br />CITY/ TATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />ATE/ZIP <br />PHONE ZA <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBERODM EXPIRATION DATE I �/N <br />DOMESTIC ELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑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: WaterSystem Name Uontact 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-Serviceell E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pum Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E) Air Rotary ❑Auger ❑Cable Tool E] 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 ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) E] 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 ❑)imensions: Width ft Length ft Thick in [_]ChristyBox ❑Stove Pipe <br />PUMP VI Submersible ❑Turbine ❑Other HP L 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 />CE REQUIRED FORiI <br />//D PARTMENT USE ONLY <br />Application Accepted By 6� Date <br />Grout Inspection By Date <br />Pump Inspection By Date 1 L 1?_O I T <br />Soil Boring Inspection By Date <br />COMMENTS <br />NS - PLEASE CALL (209 &93"7697 <br />Z(42 DATE <br />Area—t0o I Employee ID# / <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />D <br />v <br />0 <br />A <br />m <br />N <br />f// <br />PE SC Receive <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />;r - � t ►� �� �� u�P <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />