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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 PFERMIT CALL 209 9 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSCITY/ZIP m <br /> D <br /> CROSS STREET APN�7 n A' 7 D PARCEL SIZE LAND USE APPLICATIIOONN#�, 7 �j 0 <br /> OWNER NAMEUAMPHONE ' <br /> OWNER ADDRESS 1. r CITY/STATE/ZIP / /// �_/ <br /> CONTRACTOR PHONE G-Lwl✓1 <br /> CONTRACTOR ADDRESS 40d d CITY/STATE/ZIP`:� INTI <br /> SUBCONTRACTOR PHONE 40 <br /> SUBCONTRACTOR ADDRESS TY/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 WaterSystem <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well [I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11ymbiMonitoring Wells) #of wells LISoil Boring(s) #of borings F] Geotechniical PC:^— T <br /> ❑ Out-Of-Service?Pump <br /> II (i Out-Of-Service Well Renewal 11 Cross-Connection Repair "; �® <br /> El New Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION2019 <br /> Drilling Method ElMud Rotary LiAir Rotary [IAuger J, Cable Tool I 1 Push Point ElOther `SAIV JO <br /> JZjProposed Well Depth ft Excavation in diameter [I Open Bottom ❑ Gravel Pack/Grab t i V 010 qt ii meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft PAR-rM,,NT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 1-1 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I 1 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 Pump Set ft Standing Water Level ft <br /> I HEREBY CERTI Y 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 /> WORKER COMPENSATION LAWS. <br /> I MU 4>' 7kUADVANCE NOTICE REQUIRED F R INSP TIONS -PLEASE CALL (209) 53-74 '7 <br /> SIGNED ITL DATE <br /> Et <br /> DEPA TMENT USE 0NLY qq <br /> Application Accepted By . Date r 1 Area Employee ID#%! <br /> Grout Inspection By / Date 71 SPECIAL Well Permit <br /> Pump Inspection By Date i1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />