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a <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE�P•ERMIT f CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J J �/ y 4f kill. CITY/ZIP ► m <br /> D <br /> CROSS STREET APNt749=_0 PARCEL SIZE� -LAND USE APPLICATION# 0 <br /> OWNER NAMEPHONE *t CL <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE7— �LS� <br /> CONTRACTOR ADDRESS �7" L %V CITY/STATE/ZIP C. <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST <br /> `ATE/ZIP <br /> LICENSE / -57 ❑C-61 ❑D-09 ❑Other NUMBER-�� <br /> DOMESTIC WELL SAMPLING:WGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑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-z<New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> F-1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum ❑Pum Replacement ❑Pum Repair <br /> ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-CfMud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth_�1_00 ft Excavation in diameter ❑Open Bottom <Gravel Pack/Gravel Size in diameter <br /> ❑Conductgr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Z� Glastic [-]Stainless Steel ❑Otherx <br /> Grout Seal Depth p 1 ❑Neat Cement(94 Ib bag/5-10 gal water) ' $and Cement sack mix/7 gal water <br /> F-1 Bentonite(20%s ds) E]Other <br /> Grout Placement Method q<pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By iller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal(dimensions:Width_ ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ,Submersible❑Turbine ❑Other HP�Q 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 SARI <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 /> MINI H R ADVANCE NOTICE REQUIRED FOR�IN"S�P�ECCyT,IONS - PLEASE CALL (209)) 953-769)7 <br /> SIGNED TITLE D W/✓csi DATE <br /> I <br /> O <br /> A <br /> ( �1Roma, U <br /> OEPAp-rAZ <br /> DE ARTMENT SE ONLY <br /> t 1(0 <br /> Application Accepted jByt <br /> Date Area Employee ID#��.c ( <br /> Grout Inspection Date �1 ❑ SPECIAL Well Permit <br /> Pump Inspection Date " f ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 7 � C) ft <br /> C(OOMMM,E�N,TTS .���� D G �/L� �2t/ll�C-c, � 7-0Jnr �T�06 � <br /> 1-7 <br /> rz5i <br /> 7-0 <br /> PE Sc Received h Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> ?-5-i1 � 67ql <br /> EHD 43-06 8/01/16 <br />