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• WELL/PUMP PERMIT \ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />f�PERMIT CALL LUy U0.3-IbUf FOR INSPtGI IUN5 r -A IrIMIC-0 I T tAK�I-KUIVI IJA]IIIt IJJUtU <br />JOB ADDRESS (�O –ji ever rnarn la ��u n CITY/ZIP �SG'Q{ U i <br />CROSS STREET 14yOQ'i APN I, • O �W PARCEL SIZE LAND USE APPLICATION <br />#�G� <br />OWNER NAME �Jt (�Y� 5i-ptP1�r PHONE C;`D <br />OWNER ADDRESS �i� 1�► der M& rVAu CITY/STATE/ZIP E ren U n GcQ. <br />y/j/2✓/��� <br />CONTRACTOR J� l� C N PHONE /�j-� {� <br />CONTRACTOR ADDRESS IJ / /Kn CITY/STATE/ZIP,<("n <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS I t' -*— <br />LICENSE )(C-57 1.7 C-61 ❑ D-09 I1 Other <br />PHONE <br />CITY/STATE/ZIP 2 <br />NUMBER �� U EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE K Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial Ll Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Cl Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well L] Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings n Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u New Pump Pump Replacement ❑ Pump Repair I I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C] Mud Rotary ❑ Air Rotary I_I Auger ❑ Cable Tool ❑ Push Point I7 Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom D 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 Cl Plastic 11 Stainless Steel ❑ Other <br />Grout Seal Depth ft LI Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) f 1 Other <br />Grout Placement Method I I Pumped I I Free Fall LI Other Li Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller I1 Pump Contractor n Other <br />i Concrete Pedestal 1Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP V Submersible 17 Turbine I I Other HP Pump SetlfO ft Standing Water Level _Z2_57 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 />WORK M. COMPENSATION LAWS. <br />Application Accepted By <br />Pump Inspection By <br />.,wry <br />7. <br />Employee ID# <br />Well Permit <br />WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />_n <br />m <br />D <br />O <br />0 <br />m <br />m <br />N <br />V1 <br />PE SC <br />Codes Info <br />Received heck# Amount Permit/ <br />B ash emitted Date S rvice 5equest # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />