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WELL/PUMP PERMIT ✓ 1 <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 /> N <br /> JOB ADDRESS CITY/ZIP m <br /> f�7r�J D <br /> CROSS STREET APN `mow��/� PARCEL SIZE _LAAND U E A N# A <br /> ca <br /> OWNER NAME t Lel V th �F'HON' ✓-74143 c? <br /> 5 <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS Ed CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACT R ADDRESS 4TY/ISTATEIZIP <br /> LICENSE 57 ❑ C-61 ❑ D-09 [j Other NUMBER EXPIRATION DATE <br /> DOMESTIC ELL SA PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X <br /> 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 [I Soil Boring(s) <br /> #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service el ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump A/ump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION yk <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool [I Push Point Ll Other <br /> Proposed Well Depth ft Excavation in diameter I I 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 I.1 Steel ❑ Plastic El 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) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall Ll Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Cl Other <br /> ❑ Concrete Pedestal [(Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> 14 F <br /> P Submersible ij Turbine I I Other HP Pump Set ft Standing Water Level ft <br /> PUM <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 /> CURREND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE S C MPD <br /> LAW§. <br /> IN H lI E REQUIRED FO I SP -PLEASE CALL (209) <br /> SIGNED TITLE DATE <br /> DPARTMENT USE ONLY <br /> % IL <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date Ll SPECIAL Well Permit <br /> Pump Inspection By Date [I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PAY MEN I <br /> PE SC Received hec Amount Permit/ <br /> Co es Info sh emitted D t Service Request# Invoice# ell ID# <br /> 3�ss�d T <br /> IRONMENTAL <br /> HEALTH DEP <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />