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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 EXPIRES 1 YEAR FROM <br />FjDATE <br />` ISSUED <br />JOB ADDRESS' CITY/ZIP 1 v <br />CROSS $TREE PN PARCEL SIZE USE APPLICATION # <br />OWNER NAME PHONE <br />&. 614M <br />OWNER ADDRESS 14 -1 K11qq LCITY/STATE/ZIP ;_ / 5_ <br />CONTRACTORjV U PHONET/./�//�(J�/C <br />VV <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR A 1 4 A PHONE <br />SUBCONTRACT ADDRESS CIV/STATE/ZIP <br />LICENSE -57 <br />El 11D-09 11Other NUMBER quVzp—EXPIRATION DATE ✓ <br />14 <br />DOMESTIC ELL SAMPLING: 1 1 General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Pe Domestic/Private Ll Irrigation/Agricultural ❑ Industrial LI 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 ❑ Geotechnical —j�# of borings <br />Ll Out -Of -Service II [1 Out -Of -Service Well Renewal 11 Cross -Connection Repair R �kpElNew Pum Pum Re lacement F1Pum Re air 11Raise Well Casin <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary -1 Air Rotary 11 Auger ❑ Cable Tool 1.1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom ❑ Gravel Pack/Gr#Ak 4?1 8diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft /y�A1L,/p N/NCOVN <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched IJ Steel F1 Plastic F1 Stainless Steel b� <br />Grout Seal Depth ft LiNeat Cement (94 lb bag/5-10 gal water) [ISand Cement sacThtil@ JAZ gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other [I 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 Setj' 'F 0_ ft Standing Water Level(_ <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 />SIGNED <br />EP RTMENT USE ONLY <br />2d <br />Application Accepted By Date I 0// -dl x <br />Grout Inspection By {� Date a <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area44V Employee ID#� <br />11 SPECIAL Well Permit <br />I I WAIVER Received <br />Constructed Well Depth ft <br />m <br />m <br />D <br />v <br />0 <br />X <br />m <br />ur <br />PE SC Received Amount <br />Codes Info B Cash emitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />