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71n l-�lal � w to l -'A - t 10J &" <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 <br />953-7691 FOR INSPECTIONS n ,tAVIKt, 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS " 1 I/ UQ nL CITY/ZIP L-//',, <br />CROSS STREET__ O ��(/(JO �lPARCEL SIZErLAND USE APPLICATION # <br />OWNER NAME ,- e t� ' J PHONE <br />OWNER ADDRESS / CITY/STATE/ZIP (/I <br />CONTRACTOR HONE !% <br />CONTRACTOR ADDRESS MIA) iCITY/STATE/ZIP � <br />SUBCONTRACTOR PHONE <br />SUBCONTRACT ADDRESS CI ISTATE/ZIP <br />LICENSE ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br />UO' <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />11 4 <br />INTENDED USE mestic/Private ❑ Irrigation/Agricultural []Industrial ❑ Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water bystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification <br />❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) E] Geotechnical # of borings <br />El Out -Of -Service &I [:] Out -Of -Service Well Renewal <br />❑Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair <br />❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool []Push Point <br />❑ 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 <br />ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel <br />❑Plastic E] Stainless Steel E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) <br />❑ 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 E] Driller E] Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑ChristyBox ❑Stove Pipe <br />PUMP [Submersible❑Turbine ❑Other HP =L=PL Pump Set / VL2 ft Standing Water Level ft <br />I HERESY 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 />ri <br />MUM 4 VAANnCE NOTICE REQUIRED F INS CTIONS - PLEASE CALL (20TRT <br />SIGNED kcu� �FWIPJ f Y_ /1 TITLE DATE�� <br />D PARTMENT US ONLY <br />Application Accepted By -->Date l Area Q Employee ID#1~cL <br />Grout Inspection By n Date ❑ SPECIAL Well Permit <br />Pump Inspection By1AA Date 0 ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS GGi4G /U>, <br />Date <br />Constructed Well <br />ft <br />T <br />m <br />D <br />0 <br />v <br />m <br />m <br />PE Sc Received he Amount Permit/ <br />Codes Info By,,, Cash emitted Date Service Request # Invoice # Well ID# <br />t25P 410,01 114t117s� cx 0 3 Tio <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />