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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS Oq EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESSCITY/ZIP S m <br /> /� D <br /> CROSS STREET /APN V PARCEL SIZE AND USE APPLICATION# Q 0 <br /> �iQ � 1 PHONE <br /> OWNER NAME � <br /> M� �j� cn <br /> OWNER ADDRESS I �� ' CITY/STATE/ZIP�J�I�CIe"��� /� /✓�S <br /> CONTRACTOR /V 42 ) �[/(��[[6 �[���'7 F 1ft/ PHONE(i(Jg Q�l—CJS�� <br /> CONTRACTOR ADDRESS 70 w f( CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE A 4A <br /> SUBCONTRACT R ADDRESS C Y/STf/�ATEE//ZIIP <br /> LICENSE C-57 [IC-61 ❑ D-09 ❑ Other NUMBER v w EXPIRATION DATE <br /> IF - <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i i Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial I I 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 n Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement Y—Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary f I Auger a Cable Tool 1 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 11 Open Bottom a Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched IJ 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) 1 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall I Other I-) Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I I Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ StovPA <br /> e 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 /> IMU 4 URA CE NOTICE REQUIRED FOR INSP CTIONS -PLEASE CALL (209) 5 -76 <br /> SIGNED TITLE DATE <br /> U <br /> I 2S <br /> T <br /> v <br /> OUN11 <br /> r Pyr <br /> E T <br /> DE ARTMENT U E N L Y <br /> Application AcceptedBy L Date l Area Employee ID# <br /> Grout Inspection By Date FJ SPECIAL Well Permit <br /> Pump Inspection By 10� Date to j O-L kl ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount DatePermit/ Invoice# Well ID# <br /> Codes Ian-fyo� Bv Cash emitted ervi`c�e,Re,est# <br /> V, <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />