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G v/ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/Z}IP C - <br />CROSS STREET APN _ 33 2 VOO I PARCEL SIZE 2 LAND USE APPLICATION # <br />OWNER NAME PHONE "1 1 ✓ <br />OWNER ADDRESS \ .Sl CITY/STATE/ZIP r <br />CONTRACTOR _ 4 PHONE NMQ4%—A �/ o <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRAC R ADDRESS TY/STATE/ZIP <br />LICENSE C-57 El C-61 171 D-09 El Other NUMBER EXPIRATION DATE <br />DOMESTI WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells ❑Soil Boring # of borings s) ❑Geotechnical # of borings <br />❑Out -Of -Service ell ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter El Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />F-1 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 ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑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 />(MINIMUM,24 HOUR ADYANCF- NOTICE REQUIRED FOR INSPEctrIONS - PLEASE CALL (209) 95�-769j, <br />SIGNED <br />TITLE t <br />DEPARTMENT USE ONLY <br />Application Accepted By L. ti Date f " <br />Grout Inspection By p 4b� �1�' +, Date <br />4 Pump Inspection By R1_ 1/�t�Yv� Date K 1I <br />Soil Boring Inspection By Date <br />COMMENTS d (cdc' p <br />I DATE <br />IL <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Area q / (I -I Employee ID# ,/,\ ^ rnF'C't <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth / ft <br />PE <br />Codes <br />SC ReceivedCheck#1 Amount Date Permit/ Invoice # Well ID# <br />Info Cash Remitted Service Request # <br />q, f) <br />S U o 15� ab <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />