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WELL/PUMP PERMIT ILI V--*� ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(20919J3-7697 FOR INSPECTIONSP RES 1 YEAR F OM DATE ISS ED <br /> JOB ADDRESS CITY/ZIP m <br /> D <br /> CROSS STREE APN �� PARCEL SIZE AND USE APPLICATION# A <br /> OWNER NAME PHONE v, <br /> OWNER ADDRESS O2 CITY/STATE/ZIP �v — <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS JW, CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRAZ-57 <br /> ADDRESS C ./ST,ATIE//ZIP <br /> LICENSE ❑ C-61 ❑ D-09 Ll Other NUMBER v! EXPIRATION DATE <br /> DOMESTIC ELLS PILING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ,Domestic/Private rigation/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 ❑ New Well 1-1 Replacement Well ❑ Well Alteration/Modification I I Other <br /> ; <br /> ❑ Monitoring Well(s) #of wells ❑ g #of borings <br /> Soil Boring(s) Li Geotechnical <br /> ❑ Out-Of-ServicejFPump <br /> ll Ll Out-Of-Service Well Renewal CI Cross-Connection Repair A ��® <br /> ❑ New Pum Replacement ❑ Pump Repair I Raise Well Casing riPR 2 <br /> WELL CONSTRUCTION I L <br /> `ANJOqI 8 <br /> Drilling Method [I Mud Rotary n Air Rotary [I Auger Ll Cable Tool Li Push Point [I Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom LI Gravel PacklG,H QUO'MEQ n diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft MENT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I] Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 11 Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I' Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Other <br /> ❑ Concrete Pedestal I Dimensions:Width ft Length ft Thick in Il Christy Box ❑ Stove Pipe <br /> PUMP ElSubmersible❑ Turbine Y1 Other HP VIL1 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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MUM 4�) VANC OTICE REQUIRED FOR INSVECTIONS - PLEASE CALL (20 ) V53-799 <br /> SIGNED / TITLE DATE <br /> c <br /> JE <br /> 14- Ah k <br /> Vic- <br /> EPA TMENT U.SEG LY <br /> Application Accepted By , Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection ByDate ❑ WAIVER Received <br /> Soil Boring Inspection By Date onstructed We1�Depth ft <br /> COMMENTS (\J'j �(C Ct S? 1y0 ''`� b Ki C a 6/L�u 1211 i� <br /> PE SC Received hec Amount Permit/ <br /> Codes Info ash emitted Date Service Re uest# Invoice# Well ID# <br /> ILW <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />