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n <br />P ✓ <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-KEFU N DABLEaPERMI7 <br />JOBADDRESS 71.i O <br />CROSS STREET &6. <br />OWNER NAME J o h <br />OWNER ADDRESS 4`I S 0 <br />t:ALL LU`J !J5J-1bUI FOR INSPECTIONS tAt'IKtJ 7 YEAR FROM LIGATE ISSUED <br />CITY/hRIP /,�l/T / S <br />_ APN 0 `PARCEL SIZE very LAND USE APPLICATION # <br />a CU 1, , Z'4 G 4 6 / PHONE <br />Y J <br />Pe l r. n I?A CITY/STATEIZIP WO Ai4e C a, <br />ADDRESS <br />JR ADDRESS U d Y 0-1-71 <br />C-57 ❑ C-61 ❑ D-09 ❑ <br />PHONE kU <br />CITY/STATE/LP US•t„ <br />26 <br />NUMBER • EXPIRATION <br />DOMESTIC 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 />❑ Monitoring Well(s) # of wells D Soil Boring(s) a of borings 4 Geotechnical 11 of borings <br />❑ Out -Of -Service Well ❑ Out -OF -Service Well Renewal ❑ Cross -Connection Repair <br />U New rump u rump Replacement u rump Kepair u Kaise vven Lasing <br />WELL CONSTRUCTION <br />Drilling Method 14 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth S 0 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size In diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thicknesss/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth it ,p Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method„d Pumped ❑ Free Fall ❑ Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick In ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ SubmersibleD Turbine ❑ Other HP Pump Set it Standing Water Level It <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />M 1 48 DVANCE NOTICE REQUIRED FO TONNS- PLEASE <br />LEASE CALL (209) 9 3- <br />7697 <br />SIGNED-U'TITLE Yr/oi IlWf DATE 9jjqflA- <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />EPARTMENT USE ONLY 1. <br />Date ^/0 Ll(Area + / ! I Employee ID# ►t YID <br />"A &V Mate � ' �5 % I S ❑ SPECIAL Well Permit <br />Date ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />PE SC Received Check#/ AmountDate PerrntU Invoice # Well ID# <br />Codes Info 8 Cas Remitted Service Re uest# <br />U u <br />EHD 43-06 revised 4114/18 WELL /PUMP PERMIT <br />La <br />ig <br />D <br />M <br />inw <br />ENT <br />VE® <br />2018 <br />COUNTY <br />