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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-RqqjNWWjII,f PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES�1 YEAR FROM DATE/ ISSUED <br />JOB ADD S I /;' ► J <br />t� CL{�t ��} r <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />-yCITY/ZIP <br />r4 ") <br />")10 <br />SIZ41 � <br />LAND USE APPLICATION # <br />CROSS STREE <br />, ` G APN 1 1 <br />PARCEL <br />J <br />���UI <br />/�.� <br />PHONE 3 51 -11 --)t� <br />OWNER NA I �``r V, <br />li 1 I/� ( 1J�� <br />r201 <br />OWNER ADDRESS - <br />✓ i f,\.e Jt <br />CITY/STATE/ZIP <br />/ <br />�✓ t'(r _ i✓` `�� <br />CONTRACTOR <br />\ L ! ✓ �11 C G6//Y` <br />PHONE C �s )761 <br />/ <br />CONTRACTOR ADDRESS C 1—&CELL, ` "1 �U��N <br />/ <br />CITY/STATE/ZIP � <br />j(�� L� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />e L L� � <br />J z <br />DATE �/ I <br />LICENSE - 57 11C-61 <br />❑ D-09 11 Other <br />NUMBERLr <br />EXPIRATION / <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) I Dibromochloropropane (4392) I 1 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 kfYGeotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />❑ New Pump ❑ Pump Replacement ❑ Pum Ke air ❑ Kaise vveii uasin <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary "uger ❑ Cable Tool Ll Push Point ❑ Other <br />Proposed Well Depth _ft Excavation t') in diameter ❑ 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 Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft (441at Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 11 Pumped F1 Free Fall 11 Other ! fnI ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ 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 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 S i ATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MI lMUM �4�8 1-1 ADVANCE NOTICE REQUIRED FOR INSPECTIONS -`P ASE CALL (209) 953-7q97 <br />SIGNED / TITLE DATE <br />�.EPARTMENT U, E?� ONLY <br />Application Accepted By DateD Area Employee ID#-r�� <br />Grout Inspection By Date 11 SPECIAL Well Permit <br />Pump Inspection By �// ® Date / 11 WAIVER Received <br />Soil Boring Inspection By �11��Lw+—�'dr��'C Dat eC 2 ic'l1 _ Constructed Well Depth ft <br />COMMENTS PAYM <br />T <br />V <br />m <br />D <br />v <br />v <br />m <br />m <br />N <br />N <br />PE Sc Received Check Amount Date Permit/ <br />Codes Info B sh Remitted S rvice a uest # <br />Invoice ell ID# <br />!Z2 <br />OCT 3 d 201 <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />