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WELL/PUMP PERMIT <br />P✓ ' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE. PERMIT C LL (20%953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS / /� �1 CITY/ZIP <br />CROSS STREET ( AP 0 _ ` 10 -1 y 1 6 PAR�C7EL SIZE �q�` <br />{� � 1 LAND USE APPLICATION # %, ry—^' <br />OWNER NAME A Y 1 (, p I ZnnL,, PHONE / vV <br />���✓i� �fii/lG4'� AGI iv <br />RMW <br />OWNER ADDRESS CITY/STATE/ZIP ��� <br />CONTRACTOR V PHONEGU� �3/ ✓�/� <br />CONTRACTOR ADDRESS CITY/STATE/ZIP- <br />SUBCONTRACTOR I PHON <br />SUBCONTR TOR ADDRESS CI Y STATE/ZIP <br />r _ <br />LICENSE 1 `C-57 LlC-61 11D-09 I I Other NUMBER ` EXPIRATION DATE <br />)OMESTIC WELL SAMPLING:' General Mineral/Coliform Bacteria (4391) UIbromochIOropropane (4392) Arsenic (4JU3) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural I1 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />11 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well CI Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings L1 Geotechnical # of borings <br />❑ Out-Of-ServicePump <br />ll ❑ Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />F1 New Pum Replacement 11 Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1.1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter fJ Open Bottom ❑ Gravel Pack/Gravel Size�i%diameter <br />11 Conductor Casing in diameter / Conductor Casing Depth ft SqN QU/ <br />JOR.•11 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel 1_I Plastic U Stainless Steel q O r O <br />Grout Seal Depth ft 1 Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement H�'��Cj44r <br />11 Bentonite (20% solids) LI Other <br />��T�1EA/r <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I 1 Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal L1 Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine 11 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 C PENSATION I"" - <br />P64 WN I <br />Au "MWNI , %OUR /OE REQUIRED FO IINSPEe?ONS--PLEASE CALL (20SIGNED r� r� `��i7 % , ! yrTITLEX/-] �[E��l /��//iC// 1 DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By Date 3 ' 2 3 _ 1 � <br />Grout Inspection By A Date <br />Pump Inspection By ti Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# <br />11 SPECIAL Well Permit <br />I I WAIVER Received <br />Constructed Well Depth ft <br />T <br />M <br />D <br />v <br />0 <br />M <br />M <br />PE <br />Codes <br />SC Received <br />Info B <br />Chec <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />3Y W <br />U SCI <br />1ST=7 <br />i <br />Sdc <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />