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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-REFUNDA P R T CALL 209 953-7697 FOR INSPECTIONS^ ,nEX/PI ES 1 YEAR FROM TE SU D <br />JOB ADDRESS'10 U CITY/ZIP , ` V <br />i <br />CROSS STREET 1 Y PAPN/N PARCEL SIZE j�LAND USE .}P�CATIOON # ) `/ <br />OWNER NAME /i` "� (,f PHONE 1/]Y�l Z L <br />OWNER ADDRESS b l , 1` CI / /ZI V `/ {� C <br />CONTRACTOR LA G PHONE <br />CONTRACTOR ADDRESS (/V t / <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE C-57 C-61 D-09 Other16 <br />--!2- <br />NUMBER W EXPIRATION DATE <br />DOMESTIC WELLS PLING: 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 - Soil Boring(S) # of borings Geotechnical # of borings <br />Out -Of -Service W Out -Of -Service Well Renewal - Cross -Connection Repair <br />New Pum Pum Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic I Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (941b 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 i I Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set_APV ft Standing Water Level ft <br />FS <br />IHtKtBY GEKTIFY THAT I HAVE PREPARED TIIIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAW AND RULES AND REGULATIONS.. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS —1ZCUR ACTIVE WITH THE CALIFOR A CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL t) <br />KER CO ENSATION LA ��-+`1 <br />M 24 H VA E NOTICE REQUIR D F ��R,�p!NN/S /PEE]]C/TIONS - PLEASE CALL (201py.�j�9 3-769 <br />SIGNED TITLE'( l.it. l4..CA't2- DATE 1 v v <br />■■■■■■■■■■■ill■11■■■L`�'■■■■�■■■■■■■■■■■■■■■■■■■■ <br />■■■■■■■■■■■`JIB■■■■■■�■11■w■■■■■■■■■■■■■■■■■■■. . <br />■■■■■■■■■■■SSI■■■■■���■��rl■■■���������������� � <br />P <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />i■■■■■■■■■■■■■■■■■■■■■■■■sof.. <br />��:'ilrrL'�m,��i'_�'_��G�'ir��G'�1�►►'1�1�TF�.�. '" I� <br />EHD43-06 8/01116 <br />WELL /PUMP PERMIT <br />