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WELL/PUMP PERMIT P J �. <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 — EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS bosa*-�& CITY/ZIP 6 wf/ / (44 <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />APN{�jQ4 �vv PARCEL SIZE LAND USE APPLICATION # <br />U 1 Ci PHONE 323-8"� <br />LICENSE IVC -57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP L IIVWJ M - I,f}Q%i. /��i Ivy <br />G14,C� PHONE20^ I✓) ����jj1�0/ <br />CITY/STATE/ZIP � �gJ90S <br />PHONE <br />CI Y/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: I General Mineral/Golitorm bacteria (4391) Dibro ochloropropane (4392) 1 Arsenic (4393) <br />Ae <br />NTENDED USEDomestic/Private ElIrrigation/Agricultural ElIndustrial 11Water Quality Monitoring LiSoil Sampling/Characterization <br />❑ ublic 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 Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump 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 f l Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched f I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑1 Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) 1_1 Other <br />Grout Placement Method F1 Pumped ❑ Free Fall ❑ Other 1 I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller I l Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine ❑ Other HP Pump Set ft Standing Water Level (L ft <br />I HEREBY CERTI Y 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 />10 <br />SIGNED <br />Area Employee ID# "J <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />W <br />m <br />D <br />v <br />0 <br />m <br />m <br />fn <br />N <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />EPARTMENT USE PNLY <br />p <br />Application Accepted By <br />Date Q <br />Grout Inspection By <br />By <br />Date <br />lml fi 4 Date Z <br />Pump Inspection <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area Employee ID# "J <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />W <br />m <br />D <br />v <br />0 <br />m <br />m <br />fn <br />N <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />