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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 /> Ln <br /> JOB ADDRESS ��� �Yr f/ CITY/ZIP i .1 -` L c, / � <br /> m <br /> L�`�� D <br /> CROSS STREET APN `� PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME w/ PHONE <br /> OWNER ADDRESS 9Q d C-4`/ CITY/STATE/ZIP <br /> CONTRACTOR �iGt/ CC— `` l S /A/ PHONNEE/ <br /> CONTRACTOR ADDRESS �/ �> ' / O J / rL � tf(/' CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP J <br /> LICENSE 57 ElC 61 El D-09 El Other 14 NUMBER 7 <br /> !� 401 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural Industria/t,(l 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 IJ Soil Boring(s) #of borings 11 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair NT <br /> NI WQI ew Pum 11 Pump Replacement [A Pump Repair F1 Raise Well Casing C <br /> WELL CONSTRLf6TION A� <br /> Drilling Method 11 Mud Rotary [I Air Rotary F] Auger ❑ Cable Tool Ll Push Point Ll Other AfOV 0 ' pg <br /> Proposed Well Depth ft Excavation in diameter Ll Open Bottom ❑ Gravel PacWRApyj6X6b in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft HSE VRONME YTA9 Nom' <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ElSteel 11Plastic ❑ Stainless to 0 U64�� <br /> Grout Seal Depth ft I I Neat Cement(94/b bag/5-10 gal wafer) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine ❑ Other HP J 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 /> MINIMU ,88 HOUR AD NCCEENOTICE REQUIRED FOR_I S ECTIONS - PLEASE CALL (209) 953- 69 <br /> SIGNED C' (M� C'� — TITLES/`r DATE /� <br /> Df. PARTMENT USE ONLY / <br /> 7 Ff ,tfsll' <br /> Application Accepted By �'V Date ( , !�/8 Area Employee ID <br /> Grout Inspection By V Date Ll SPECIAL Well Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection y Date Constructed Well Depth ft <br /> COMMENTS r,r fQ VIJP ay, j <br /> PE SC Received C CheSqV Amount Date Permit/ Invoice# Well ID# <br /> Codes InfoB s Remitted Service Re uest# <br /> 0 1-0'-I 3 W Poo <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />