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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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V CITY/ZIP m <br /> l� D <br /> CROSS STREET �� APN v� PARCEL SIZE�LLAND USE AP`PLLICATION# (,t l r,y�! A <br /> PHONI V �� � 1.] �' \ m <br /> OWNER NAME �t �� ^/� �/L N <br /> OWNER ADDRESS L V ` �-! CITY/STATE/ZIP <br /> CONTRACTOR 0 � I� �(� lIV) PHONE ` <br /> CONTRACTOR ADDRESS l`T ' CITY/STATE/ZIP <br /> SUBCONTRACTOR 1� V 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) i 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 CI Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method /)(.Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation I a in diameter f_1 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 DR)_ i i Steel )(Plastic El Stainless Steel F1 Other <br /> Grout Seal Depth �� ft fl Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placemet Method Pumped ❑ Free Fall ❑ Other I1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor 1-1 Other <br /> )(Concrete Pedestal I-0imensions:Width ft Length__�57 ft Thick in ❑ Christy Box C1 Stove Pipe <br /> PUMP Submersible❑ 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 COMPENSAT ON LAWS. <br /> MINI U UR CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 9 3-769 <br /> SIGNED TITLE 0 J DATE 1 <br /> j <br /> OiJNTY <br /> E VI O fy1 NT .L <br /> DEPt RTM ENT USE ONLY <br /> Application Accepted By DateZZA Area Employee ID#� <br /> Grout Inspection By Date 3 F SPECIAL Well Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection By / Date Constructed Well Depth ft <br /> COMMENTS IAI LC A <br /> PE Sc Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Ifo By ash Remitted Service Request# <br /> 2c� - 2 °I _ .-) <br /> 7_4119 VON '�Zpl <br /> 1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />