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• y` WELL/PUMP PERMIT <br />SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE <br />JOB ADDRESS <br />Uct <br />CROSS STREET <br />CITY/ZIP <br />OWNER NAME <br />PARCEL SIZE lel, L <br />LAND USE APPLICATION # <br />0 3 <br />OWNER ADDRESS <br />C 1 <br />CONTRACTOR <br />L✓!� <br />CITY/STATE/ZIP <br />CONTR,LCTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE AR C-57 ❑ C-61 <br />L <br />APN <br />❑ D-09 ❑ Other <br />953-71597 FOR INSPECTIONS <br />EXP KES 1 YEAR FROM DATE ISSUED <br />Uct <br />i G+ Lqf!94 o <br />CITY/ZIP <br />, <br />- <br />PARCEL SIZE lel, L <br />LAND USE APPLICATION # <br />0 3 <br />C <br />PH 9 NE , <br />L✓!� <br />CITY/STATE/ZIP <br />I LJf <br />1](� <br />PHONE (/ `tel `�3 1V <br />CITY/STATE/ZIPS <br />ckm 1� <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE f Domestic/Private ❑ Irrigation/Agricultural I I Industrial ❑ 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 CI Replacement Well ❑ Well Alteration/Modification Il Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pumo .#Pump ReDlacement t I PumD Repair CI Raise Well Casino <br />Drilling M hod ❑ Mud Rotary a Air Rotary F1Auger Ll' able Tool ❑ Push Point 11dyle <br />Proposed II Depth ft Excavation diameter 1 Open Bottom a\` <br />\DDe <br />ductor Casing in diameter / <br />Co <br />or Casing Depth <br />Well Casinter in Thickness/Gauge/ASTM Sched I I Steel ❑ Plastic <br />Grout Seft IJ Neat Cement (94 Ib bag/5-10 g water) 11 Sand Ce <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped Cl Free Fall Cl Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller ❑ Pump Contractor I1 Other <br />I_l Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />ravel Pack/Gravel Size <br />finless Steel ❑ Other <br />lent sack <br />in diameter I <br />I water I <br />PUMP .rSubmersible❑ Turbine of Othert F N HP t 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 />77k& -,ADVANCE NOTICE REQUIRED FOa NSSPECTI N`S--�PLFASE CALL (209) 95 -'22 <br />7%69/7 <br />SIGNED / TITLE _ <\ 1C wokl _ DATE L� L- <br />ARTMENT USE ONLY <br />Application Accepted By �/� Date I ,.21 - <br />Grout Inspection By ^n Date <br />Pump Inspection By Date 124 <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area QG Employee ID# w c1l) �J <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />-4 <br />m <br />D <br />v <br />0 <br />M <br />M <br />or <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />B C h <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />`W <br />S'E <br />0 3 <br />17 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />