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WELL/PUMP PERMIT <br />Q ✓� <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 09 953-7697 FOR INSPECTIONS 04 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET APN " ' !/ / r �P`ARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME 'V! A PHONErXI / /M '/4 �fl �--3 B <br />OWNER ADDRESS CITY/STATE/ZIP TT-- <br />CONTRACTORVI/PHONE <br />i. <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR / \ �1/ 1 PHONE <br />SUBCONTRATpR ADDRESS <br />LICENSE //)C-57 ❑ C-61 ❑ D-09 ❑ Other N <br />EXPIRATION DATE <br />)OMESTIC WELLAMPLING: ❑General Mineral/Coliform Bacteria (4391) LjDibromochloropropane (4392) LjArsenic (4393) <br />I- <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural [:]Industrial ❑Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name L;ontact 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-Serviceell ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />E]New Pump 9Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] 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 E] 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 ❑ Other <br />❑Concrete Pedestal Ljimensions: 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 CER IFY 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 OMPENSATION LAWS. <br />tIN UM 24 OU . AN E NOTICE REQUIRED FO I SPEC �PLEASE CALL (209/)3- 6 7 <br />SIGNED , }IM ) TITLE FO <br />L•(�/` \ DATE ej <br />DE <br />�ARTMENT U E NLY <br />c <br />Application Accepted B Datewr7 <br />1 <br />Grout Inspection By ''I� Date <br />Pump Inspection By Mr».rv` Date7bl. III <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Cl) <br />P <br />I <br />Area 4f, Employee ID#e:;M v <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Chec Amount Date Permit/ Invoice # Well ID# <br />Codes Info By_ ash Remitted Service Request # <br />FT - <br />D 55 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />