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WELL/PUMP PERMIT <br />V � 2 <br />SAN%JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT s'. (:ALL ZUy U53-/1by/ FOR INSPECTIONS <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET ` APN '\ F <br />OWNER NAME ` 1 <br />OWNER ADDRESS O <br />CONTRACTOR JI <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />ARCEL SIZE <br />"-r tl d <br />CITY/S <br />r_ArIKCJ "I TEAK I-KUM UA I t 155UtU <br />USE APPLICATION #, <br />._ 113 %lll . 0 t <br />PHONE �V <br />CITY/STATE/ZIP �tckan CIA 26Z rs <br />PHONE / <br />SUBCONTRACTOR ADDRESSITY/STATE/ZIP <br />LICENSE 11C-57 1.1 C-61 F1D-09 ❑ Other NUMBER 4LPNU EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial i I 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 1 Replacement Well ❑ Well Alteration/Modification ❑ 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 NV�UmD ReDlacement ❑ PumD Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool _I Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I I 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 ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Ll Other <br />II Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box I I Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HPit 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 />7AQ7 <br />SIGNED <br />EP RTMENT USE NLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />;r <br />Area Employee ID#A� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Permit/ <br />Codep Info B Cash emitted Date Service Request # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />