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�t 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 <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />-AND USE APPLICATION # <br />LLQCITY/S/���il . .� �% ' <br />PHONE <br />y <br />LICENSE C-57 ❑C-61 F1 D-09 ❑Other NUMBER EXPIRATION DATE <br />DOMESTI WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />NTENDED USE ❑Domestic/Private Irrigation/Agricultural []Industrial []Water Quality Monitoring [I 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 f borings <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair moi' & pjV7- <br />n New PumD k PumD Replacement n PUmD Repair n Raise Well Casino <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other 2012 <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom [-]Gravel Pack/Gravel Si2�6t,V in diameter <br />UIP4 Co <br />171 Conductor Casing in diameter / Conductor Casing Depth ft HEENL IROyMElVTAL <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑OtFiely DEPARTWW <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Benton ite(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 EDimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HP Pump Set_LLL0 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 COMPENSATION LAWS. <br />c <br />7ARTMENT UZE ONLY <br />3/ <br />Application Accepted By <br />"/ Date <br />Grout Inspection By <br />Date <br />Pump Inspection By � - <br />Date v,, 2. <br />Soil Boring Inspection By <br />COMMENTS <br />W <br />M <br />m <br />a <br />v <br />v <br />m <br />ur <br />y <br />Area Employee ID VVv/ <br />E]SPECIAL Well Permit <br />E]WAIVER Received <br />Constrocted Well Depth _ ft <br />PE Sc Received Check Amount Permit/ <br />cocips Info B sh emitted IDate Service Request # Invoice # Well ID# <br />W-00'117YOI VJF6103 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />