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-f V,-t-Et"J 5(an ( -H-(7 � P <br /> 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 t' CITY/ZI m <br /> ��JJ�� D <br /> CROSS STREET PN Z 0�(/CJ PARCEL SIZE - LAND USE APPLICATI N# A <br /> OWNER NAME t kA' i PHONE y- ,��J// N <br /> D <br /> OWNER ADDRESS l CITY/STATE/ZIP `-Do <br /> CONTRACTOR �/ HONE <br /> CONTRACTOR ADDRESS tau CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTQR ADDRESS CITY/STATE/ZIP <br /> LICENSE VC-57 El C-61 El D-09 El Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SA PLING:❑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 uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F-1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump kPump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter L]Open Bottom L]Gravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible ❑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 /> W. N 11.1t24 UR ]ANCE IlkNOTICE REQUIRED FO I SPECT NS - PLEASE CALL (209) 953-76`97 <br /> SIGNE / TITLE DATE <br /> 7L I'Ll. <br /> T <br /> cti,✓ <br /> o �ti <br /> DE ARTMENT U E ONLY <br /> t <br /> Application Accepted B� v Date 1 Area Employee ID#lr;�51 Z0 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspectio Date �i / ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received K1111heqq Amount Date Permit/ Invoice# Well ID# <br /> Codes Info qy, sh Remitted j j Service Request# <br /> 0ZP `3 eta_7 5 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />