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P/ <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 />JOB ADDRESS 22at ex� CITY/ZIP S <br />j� <br />CROSS STREET /• A-1 "PC— w D`� PARCEL SIZE �'� LAND USE <br />APPLICATION #/� <br />OWNER NAME V f J L� rPHONE !/V- I✓/ 4 <br />OWNER ADDRESS I 910"L <br />CONTRACTOR V <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE \'�C-57 ❑ C-61 <br />❑ D-09 ❑ Other <br />LILT CITY/STA' <br />NUMBER <br />PHONE X31 �lD <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />)OMESTIC WELL S PLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑Monitoring Well(s) # of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />❑Out-Of-Serviceell E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />F-1NewPump Pump Replacement F-1 Pump Repair El Raise Well Casing <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool []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 lb 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 dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible ❑Turbine ❑Other HP Pump Set_l_&O ft Standing Water Level ft <br />I HEREBY CERflY 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 />T <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Cn <br />Area Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Amount Date Permit/ Invoice # Well ID# <br />Codes Info B as Remitted Service Request # <br />2 00 3-16 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />EPARTMENT USE ONLY <br />Application Accepted By /� <br />f <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection ByPN(l�1 f�f(l� <br />I I',� �� <br />I� fJ Date (7i <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Amount Date Permit/ Invoice # Well ID# <br />Codes Info B as Remitted Service Request # <br />2 00 3-16 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />