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n <br />4 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIIT%L LL ZU5 953-/bU/ FOR INSPECTIONS t)lF� 1Ktb 'I TEAR FRUM L/AIE I55UEU <br />JOB ADDRESS !/ Co"LOAM Ci_- CITY/ZIP V� v 15 <br />CROSS STREET I� APN (j'0 17 I PARCEL SIZE I• q q LAND USE APPLICATION # <br />OWNER NAME PHONE <br />Z60 ox -!5saq <br />OWNER ADDRESS LrnwiCITY/STATE/ZIP _94AM (A_ <br />CONTRACTOR PHONE 1 L <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE /C-57 11 C-61 ❑ D-09 1 Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial -1 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well LI Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings f_l Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I I New Pump )r—Pump Replacement I Pump Repair II Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method L I Mud Rotary ❑ Air Rotary ❑ Auger [ I Cable Tool I Push Point Li Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom LI Gravel Pack/Gravel Size in diameter <br />CI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel tl Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped L I Free Fall ❑ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor N Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP YSubmersible ❑ Turbine CI 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 />MU H VANCE NOTICE REQUIRED Fnt, <br />NNSP TIONS - PLEASE CALL (209) 9 <br />SIGNED /% TITLE DATE 12 <br />`-P-A[?llVSW DEPARTMENTUSEONLY <br />Application Accepted By Date v, - C Y <br />Grout Inspection By Date It I <br />Pump Inspection By Date nZ <br />Soil Boring Inspection By _ Date _ <br />COMMENTS <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />;rt <br />m <br />D <br />v <br />v <br />rn <br />m <br />in <br />PE <br />Codes <br />SC Received <br />Info B <br />Check#/ Amount <br />Cash Remitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />3 I <br />OS u <br />I `gS <br />1- <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />