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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 /> JOB ADDRESS d CITY/ZIP V Ln <br /> / m <br /> ) I L11 <br /> D <br /> CROSS STREET APN/ 2n�7 bO I PARCEL SIZE - LAND USE APPLICATION <br /> /# A <br /> �LrV/ �1 /� <br /> OWNER NAME P�H/O�NE m y <br /> OWNER ADDRESS CITY/STATE/ZIP / �lit/1.�DiJ. lJ' i �✓/��� <br /> CONTRACTOR f,�/ `/ L PHONE �f <br /> CONTRACTOR ADDRESS 2--I Zo Pr 1 Gn�_ bGl�_ CITY/STATE/ZIP 4SjwWDn, C,4 / <br /> SUBCONTRACTOR PHONE ^� <br /> SUBCONTRACTOR ADDRESS CI/TY_/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 I Other NUMBER L!/ EXPIRATION DATE / 3 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 11 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 I I Well Alteration/Modification 1 Other <br /> Monitoring Well(s) #of wells I1 Soil Boring(s) #of borings I Geotechnical #of borings <br /> ❑ Out-Of-Service Well I I Out-Of-Service Well Renewal a Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement )(Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION / �,-r ��Jc& <br /> Drilling Method IJ Mud Rotary ❑ Air Rotary [I Auger Ll Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 11 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 1 Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) _1 Sand Cement sack mix17 gal water <br /> 11 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 11 Pump Contractor 11 Other <br /> ❑ Concrete Pedestal L]Dimensions:Width ft Length ft Thick in Li Christy Box ❑ Stove Pipe <br /> 41 <br /> PUMP K.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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> FW <br /> h►T <br /> S 19 <br /> 17.1 M <br /> 2 <br /> T F <br /> T <br /> DE ARTMENT SE ONLY <br /> Application Accepted By c Date Area Employee ID# / <br /> Grout Inspection By t� t� Date ❑ PECI L Well Permit / <br /> Pump Inspection By P�rb� \ANSIb ( � A` A Date 1108 CI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Request# <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />