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IV"r')t,�� � tcw, �-L-i- t 07V^ f t✓ <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CA 209 953-7697 FOR IAPFFTIONS EXPIRES 1 YEAR FROM ATE ISSUED <br /> JOB ADDRESS CITY/ZIP /�Z L m <br /> CROSS STREET APN d7(J � 'U� PARCEL SIZE/-K-LAND USE APPLICATION# A <br /> OWNER NAME PHONE — ch <br /> OWNER ADDRESSI ILL CITY/STATE/ZIP <br /> CONTRACTOR PHONNEE <br /> ll <br /> CONTRACTOR ADDRESS CITY/STATE/ZIFt �( � t `� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACT R ADDRESS Z CtITYIS-TATE/ZIP <br /> LICENSE C-57 ❑C-61 El D-09 El 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 []Water Quality Monitoring ❑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 #of borings <br /> ❑Out-Of-Service II E]Out-Of-Service Well Renewal ❑Cross-Connectior Repair <br /> E]New Pum Pum Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter E]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 ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb 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 /> El concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CE14TIFY 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 /> IMU 24 UR NC�-� J�OTICE REQUIRED FO INSP CTI NS - PLEASE CALL (209) <br /> SIGNED /l! TITLE DATE / <br /> R N <br /> '01 all(v JA <br /> Vv NJ <br /> F <br /> .4. I I I .y Oq <br /> 11 t11 <br /> lM Np <br /> D PARTMENT U E ONLY <br /> Application Accepted B � Date ( Area Employee ID# <br /> �� <br /> Grout Inspection B�t/� ate ❑' PECIAL Well Permit <br /> Pump Inspectio y '�; Date / ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC P..sceived L9040P Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 03 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />