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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT LL 209 53-7697 FOR IN PECTIONSPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS IN CITY/ZIP <br />CROSS STREET xi, APN e 22 — 1h) 7J PARCEL SIZE L/ LAND USE APPLICATION # J <br />OWNER NAME PHONE-zq-,� -7 — <br />OWNER ADDRESS A 10 CITY/STATE/ZIP <br />CONTRACTOR/47/PHONE !�(/g/C/��_c/�,�/��r�r <br />CONTRACTOR ADDRESS r���>l CITY/STATE/ZIP 1'__A <br />SUBCONTRACTOR ♦ I A PHONE AI / 4 <br />LICENSE <br />)R ADDRESS L f <br />C-57 ❑ C-61 ❑ D-09 ❑ Other <br />A <br />NUMBER 11,6 W EXPIRATION DATE <br />)OMESTIC WELL PLING: General Mineral/Golitorm Bacteria (4391) Dibromocnloropropane (439z) Arsenic (4saa) <br />NTENDED USE &Domestic/Private El Irrigation/Agricultural ❑ Industrial Ll Water Quality Monitoring ElSoil 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 ❑ Other <br />❑ Monitoring Well(s) # of wells I 1 Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Welf ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump um Replacement n Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom 11 Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I_I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft I I Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) I I Other <br />Grout Placement Method Ll Pumped 11 Free Fall 11 Other [I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller (I Pump Contractor ❑ Other <br />Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in I I Christy Box C Stove Pipe <br />PUMP IVSubmersiblell Turbine 11 Other HP Pump Set It 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 />WORKER&LOMPENSATION LAWS. <br />d Ij 1 "IMN'. <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />ARXMENT <br />Date <br />Date <br />Date <br />Date <br />E ON LY <br />1 <br />Area 17 Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />m <br />m <br />D <br />0 <br />v <br />m <br />m <br />PE Sc Received <br />Codes Info By <br />Check#/ Amount Date <br />Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />i os� 7 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />