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40 ' WELL/PUMP PERMIT P--� <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 l �✓ ✓ / SS S W CITY/ZIP ` 7 J J m <br /> D <br /> CROSS STREET-,a" y-` of/ APN oZ V? " /S-d -7D PARCEL SIZ LAND USE APPLICATION# A <br /> OWNER NAME T- _ �20 <br /> r PHONE 6J!f �� / j <br /> OWNER ADDRESS CITY/STATE/ZIP �SC / ` U -7-2-e <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 I1 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial CI Water Quality Monitoring ❑ 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells Cl Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTfUh- <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 1-1 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I I 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 /> Cl Bentonite(20%solids) CI Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall I1 Other I I Retardant/Accelerator(name) <br /> PEDESTAL I stalled By ❑ Driller f1 Pump Contractor ❑ Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 11 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CE I Y 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 C AT ON LAWS. <br /> MI I UM 4 A NC NOTICE REQUIRED F I/N,SPECTIONS - PLEASE CALL (209).953-7697 <br /> SIGNED TITLE it/E,�' DATE 7 : 3 " <br /> ISAM, A UIN COLNT( <br /> dEINTAL <br /> DEP TMENT U E O LY <br /> Application Accepted By Date Area Employee ID <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By i t Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS f CC,I tTr ►.� P +. c ����=1 �� /l <br /> PE Sc Received heckAmount ate Permit] Invoice# Well ID# <br /> CocLes Info Cash Remitted Service Reguest# <br /> Po y a <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />