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209= 412- 05 5 <br /> 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 /> N <br /> JOB ADDRESS CITY/ZIP m <br /> pq D <br /> CROSS STREET 7 APN DO `DY� "- l� PARCEL SIZE Z LAND USEE/AC�PPLICAJTI�O/Nq/#�/r�� r/7� <br /> OWNER NAME PHONEC_t/� '( f'06 te l`/ m <br /> N <br /> OWNER ADDRESS D 1�/ /� V- 1 CITY/STATE/Z <br /> CONTRACTOR PHONE 7 L s �lLLj� <br /> CONTRACTOR ADDRESS e4lCITY/STATE/ZIP <br /> lJ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 6 -L�113 <br /> C-57 11 C-61 F]D-09 El Other NUMBER 4bmp EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)[-]Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact 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-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> E]New Pum E)Pump Replacement El Pump Repair DdRaise Well Casing cy- /Z <br /> am <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 ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F1 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 Other <br /> E]Concrete Pedestal Epimensions: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 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 COMPSATION LAWS. <br /> MINI / CE NOTICE REQUIRED FOR IINJnSPECTIONS - PLEASE CALL (209)76 7 <br /> SIGNED l TITLE G�" LL DATE <br /> I <br /> h, <br /> �. <br /> N R N E A <br /> N <br /> DEPARTMENT USE ONLY <br /> �7 <br /> Application Accepted By Date S Z j / Area Employee iD# F C CM <br /> Grout Inspection By "�� A ,��n�� Date E] SPECIAL Well Permit <br /> Pump Inspection By QjrxV lY4Yrvwy Date 1` Z ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />