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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 /> �� m <br /> 9� s <br /> JOB ADDRESS CITY/ZIP m <br /> � (� 17 <br /> D <br /> CROSS STREET A P N (v 0 0 /PARCEL SIZE /b�LAND USE APPLICATION# <br /> m <br /> OWNER NAME PHONE C <br /> OWNER ADDRESSoil CITY/STATE/ZIP �] v <br /> CONTRACTOR DDUkIA 4kjws PHONE-��/���^t (Z <br /> CONTRACTOR ADDRESS 20 CITY/STATE/ZIP fNov <br /> SUBCONTRACTOR PHONE 4 ) 14 <br /> SUBCONTRACTO ADDRESS C Y/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 F1D-09 11 Other NUMBER EXPIRATION DATE <br /> DOMESTIC ELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> Of <br /> INTENDED USE X Domestic/Private ❑ Irrigation/Agricultural f l Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ ublic 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 0A <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Repair vlzuElve® <br /> D. New Pum Y—ump Replacement ❑ Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION 2019 <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool [I Push Point ❑ Other 8AN J +J <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom LI Gravel Pack/Gra i RON V� i meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft EPARTIMENT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By CI Driller ❑ Pump Contractor 1 Other <br /> ❑ Concrete Pedestal Li Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine 11 Other HP Pump Set ft Standing Water Level <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 /> MI 4 DVANCE NOTICE REQUIRED FOR 1 SP,ECCTIIONS -PLEASE CALL (209) 953776 7 <br /> SIGNED TITLE �;C'/L� DATE <br /> t EPARTMENT USE ONLY ��yy����,//��� <br /> Application Accepted By Date `/ Area S�"'`^'>=niployee ID#:S — <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date �4 `Z\51 21J��T ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount DatePermit/ Invoice# Well ID# <br /> Codes Info B ` Cash Remitted ere Re uest# <br /> 09`0 d4W IZVW <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />