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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 j�CALL 209 953-7697 FOR INSPECTIONS �//�EXPIIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1� CITY/ZIP Iy'(__'y m <br /> s6"W ,)tRH�L LL s zj�0 o� o,?� <br /> CROSS STREET A I' Zc/ J I PARCEL SIZE'S LAND USEIAPPLICATION#/ 1 M <br /> OWNER NAME /\(� `�I �I U PHONE_,t_O )I « I 1 U? <br /> OWNER ADDRESS n ' ^ '� C4 ITTYY/,STATE/ZIP <br /> CONTRACTOR (�J�P/ '/���( �/t�//�C/JI� 1 �r��/'` LD1 AD VU LJ PHONE <br /> CONTRACTOR ADDRES,�S/ .Jt��6 L-A M►'' �'yr c.1 Ra.l— CITY/STATE/ZIP ��L�f ✓" /' <br /> SUBCONTRACTOR /VA PHONE�x DV <br /> SUBCONTRACTOR ADDRESS AA CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ✓ %7 EXPIRATION DATE 3 <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private X <br /> 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 Fl 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 W II ❑ Out-Of-Service Well Renewal El Cross-Connection Repair �iqY� <br /> 1-1NewPum Pum Re Replacement ❑ Pum Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION Atl <br /> V�® <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Ll Push Point ❑ Other J <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom LI Gravel Pack/Gravz��� iameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft )Y d"'% / NC <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br /> Ll 11 Plastic ❑ Stainless Steef ' OU/V <br /> Grout Seal Depth ft CI Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement Sa� gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller x Pump Contractor 11 Other <br /> Concrete Pedestal I IDlmensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP A Submersible C1 Turbine ❑ Other HP�- 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 /> IM M 48 AD CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9537 <br /> 5 -77/. <br /> SIGNE TITLE ri�//_�/_��/L DATE J <br /> ,DEPARTMENT USE //ONLYC� <br /> Application Accepted By <br /> VDate ` �0 / Area q Employee ID# « 4'y1 <br /> Grout Inspection By Date El SPECIAL Well Permit <br /> Pump Inspection By ) Date 1J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />