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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 DATE ISSUED <br /> JOB ADDRESS ' /�T CITY/ZIPL G <br /> c �C, �_ m <br /> n <br /> CROSS STREET 1 PN U PARCEL SIZE��LAND USE APPLICATION# <br /> OWNER NAMEPHON i x� '�1Jy <br /> OWNER ADDRESS _ CITY/STATE/ZIP , // <br /> Ike ` E�L �J/ / <br /> CONTRACTOR 1 PHON <br /> CONTRACTOR ADDRESS � � v r! CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C TYISTATE/ZIP <br /> LICENSE C-57 ElC-61 [:1D-09 ❑Other NUMBER- EXPIRATION DATE <br /> DOMESTI ELLAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)[:]Arsenic(4393) <br /> INTENDED USE fomestic/Private ❑Irrigation/Agricultural []Industrial ❑Water Quality Monitoring ElSoil Sampling/Characterization <br /> Public WaterSystem <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-ServiceVump <br /> ll ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> El New Pum Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION It <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger [:]CableTool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation 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 Sched ❑Steel ❑Plastic ❑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 ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Oiher <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP EKSubmersibieElTurbine ❑Other HPD.5 Pump Set ft Standing Water Level -7-4 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 COMPENSATION LAWS. <br /> IMUM 4ffkDYANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76P7 <br /> SIGNED TITLE " DATE <br /> r <br /> 1 <br /> 13.0 <br /> A A <br /> "NV'RCNfvEN <br /> R E 7- <br /> DE ARTMENT USE NLY <br /> Application Accepted By �4Date Area Employee ID#;�dr-rd <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ` Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS cAn } Wit'.�l ✓� <br /> J I <br /> PE SC Received heck Amount OhAE-UUTNI(35 <br /> Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> _Wff0_Nq MI5 <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />