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WELL/PUMP PERMIT / <br />SAN! JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CA 209 953-7697 FOR INSPECTIONS tAVIKt, "I TEAR FRUM UA It Ibbutu <br />JOB ADDRESS CITY/ZIP m <br />/f �j D <br />CROSS STREET APN / PARCEL SIZE!/ / LAND USE APPLICATION #)VA10A <br />En <br />OWNER NAME�)40 PHONE 1 0? <br /><_sOWNER ADDRESS CITY/STATE/ZIP `� L <br />loCONTRACTOR WAYy,PHONE <br />CONTRACTOR ADDRESSiV <br />CITY/STATE/ZIP O( <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER V91(EXPIRATION DATE <br />DOMESTIC WELL SAMPLING:, General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />VTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I_I Water Quality Monitoring ❑ Soil Sampling/Characterization <br />1_I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK LI New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />1_-1 Out -Of -Service Well [I Out -Of -Service Well Renewal a Cross -Connection Repair <br />[I New Pump 0Pump Replacement Pump Repair ❑ Raise Well Casing <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool [I Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter LJ 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 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft I 1 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 I I Pumped ❑ Free Fall I I Other 11 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 VSubmersible ❑ Turbine 1-1 Other HP Pump Set ft Standing Water Level 8_5 �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 COMPENS, ION LAWS. <br />MIM IDM IiOUR ADVANCE NOTICE REQUIRED FORINSPECTJONS - PLEASE CALL (209) 953J.76971 <br />SIGNED <br />C <br />DATE C.. <br />D ARTM ENT VSE N L Y <br />Application Accepted By Date <br />Grout Inspection B Date <br />P Y <br />Pump Inspection By : Date 0Z <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 4*1Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC ReceivedChec Amount <br />Codes Info ash emitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />