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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 CITY/ZIP <br />CROSS STREE API -/S--PARCEL SIZE/LAND USE APPLICATION # <br />OWNER NAME JocLn Rct i - E <br />PHON` 1 6L — 13f�7 <br />OWNER ADDRESS , A uw l/ VJ CITYISTATE/ZIP 157 OUKIMq� /' � <br />CONTRACTOR PHONE q3/ -3all) <br />CONTRACTOR ADDRESS W CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTRR ADDRESS CI /STATE/ZIP <br />LICENSE C-57 ❑ C-61 [ID -09 El Other NUMBER EXPIRATION DATE 0 ME <br />DOMESTIC WELLS MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑New Well E] Replacement Well ❑Well Alteration/Modification El Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings # of borings <br />❑Geotechnical <br />E] Out -Of -Service Wfflll ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump KPump 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 ❑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 El Stainless Steel E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />E] Bentonite (20% solids) F-1 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 />If <br />PUMP ff 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 />CURRENTAND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKED COMPENSATION LAWS. , <br />CE REQUIRED <br />SIGNED <br />D PARTMENT USE ONLY <br />Application Accepted By Date <br />36 <br />Grout Inspection By Date <br />Pump Inspection By Date I<© I <br />Soil Boring Inspection By Date <br />COMMENTS <br />PLEASE CALL (2099))j9 3-/7607 <br />1 neTr�1./' 6 ,� <br />W <br />1 <br />m <br />0 <br />0 <br />0 <br />m <br />m <br />m <br />Cl) <br />R <br />7 <br />Area Employee ID#15�w-fo <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check # Amount pate Permit/ Invoice # <br />Cods Info B as Remitted see viicce Request # <br />Well ID# <br />05-D 14�10' 7 S n %-) <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />