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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL.(209)-953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DA I t iaoucU JOB ADDRESS( CITY/ZIP�J r 8 CROSS STREET&VVI 'APN //CJ r `� ✓" PARCEL SIZE C/ LAND USE APPLIC/A^TION # OWNER NAME PHONE" OWNER ADDRESS VA CITY/STATE/ZIP CONTRACTOR HONE / 11' ✓<''�iLJ CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR AN PHONE ADDRESS ATE/ZIP It r r LICENSE 6-57 ❑ C-61 ❑ D-09 I I Other NUMBER / EXPIRATION DATE DOMESTIC 4ELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial L 1 Water Quality Monitoring ❑ Soil Sampling/Characterization Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Ll Geotechnical # of borings ❑ Out -Of -Service ell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ❑ New Pump Pump Replacement I I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary i] Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel U Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) 11 Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller 11 Pump Contractor t I Other n Concrete Pedestal ❑IDimensions: Width ft Length ft Thick in I1 Christy Box ❑ Stove Pipe PUMP I Submersible F1 Turbine 11 Other HP Pump Set 11 4ml U ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKER$ OMPENSATION LAWS. SIGNED PRRT^AENT -7S�E ONLY Application Accepted By Date v! Grout Inspection By Date Pump Inspection By q Date v ZZ Soil Boring Inspection By Date COMMENTS Area Lptgqq Employee ID#� IL SPECIAL Well Permit LI WAIVER Received Constructed Well Depth ft PE SC Received Chec Amount Permit/Co s Info B Cash emitted Date Service Request # Invoice # Well ID# Vv EHD 43-06 8/01/16 WELL /PUMP PERMIT 0,