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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 9 3-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS EL Ll I r CITY/ZIP &k m <br /> CROSS STREET ���l=-Y r ` ��I APN `v t ` PARCEL SIZE_LAND USE APPLICATION# rn <br /> OWNER NAME �l ��pL ^ �� C PHONI <br /> OWNER ADDRESS L V ` �/ CITY/STATE/ZIP <br /> CONTRACTOR C1 ` ( I t PHONE <br /> CONTRACTOR ADDRESS I`-'( � CITY/STATE/ZIP <br /> 1 Vim✓ C7�� h <br /> SUBCONTRACTOR 1� I ✓`� ONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ 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 Contact Name or Phone Number <br /> TYPE OF WORK )(New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑I Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method .Mud Rotary ❑ Air Rotary El Auger El Cable Tool tl Push Point 11 Other <br /> Proposed Well Depth�ft Excavation �a in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sche D�Z ❑ Steel XPlastic [_1 Stainless Steel ❑ Other <br /> Grout Seal Depth VD ft Ci Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placerner 4Method Pumped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By X Driller I1 Pump Contractor 1-1 Other <br /> Concrete Pedestal F]Dimensions:Width ft Length S ft Thick in Li Christy Box F1 Stove Pipe <br /> PUMP XSubmersible❑ Turbine 11 Other HPOZ— 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 COMPENSAT ON LAWS. <br /> MINI U U7RA1Y111MCE NOTICE REQUIRED FOR INSPECTIONS PLEASE CALL (209)i9 3-769 <br /> SIGNED TITLE LJwI�r I '1 DATE 1 <br /> 0r <br /> r.t, <br /> N <br /> EN VIF 0 ME NT,L <br /> A L <br /> DEPRTMENT USE ONLY Q <br /> Application Accepted By Date UZ�/fq Area "[ Employee ID ���-" / <br /> Grout Inspection By Date 3 vof° ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Q �^ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS IA <br /> PE SC Received C Amount Permit/ <br /> Codes 1 fo B Cash emitted Date Service Request# Invoice# Well ID# <br /> 2u - 2 19 � <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />