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WELL/PUMP PERMIT <br /> •" SAN.IOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953;Z697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I r CITY/ZJP `� r7i <br /> CROSS STREET N LTJ APN 0 2i,—M- -�ARCEL SIZE:ZA)v LAND USE A(�P(P�LICATION# A <br /> OWNER NAME , (�C (�PHONQ.Q-/. <br /> OWNERADDRESS •'^'`Vv + CITY/STATEZP <br /> CONTRACTOR N�'(��T"� y��V`L/'l 1/�1 I I\ �J�. I-, PHONE 2i. ILTI�e /D`��,1�.' <br /> CONTRACTOR ADDRESS 1�On,1 ),e I L't"L4 ID CITY/STATEZP 6"Vx L 0413 41 <br /> SUBCONTRACTOR N PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP "� r� <br /> LICENSE C-57 C-61 I!D-09 ::Other I ExPIRATION DATE ./"" V <br /> DOMESTIC WELL SAMPLING: 'General Mineral/Coliform Bacteria(4391) Dibr mochloropropane(4392):-- Arsenic(4393) <br /> INTENDED USE Domestic/Private I:Irrigation/Agricultural is Industrial -i Water Quality Monitoring Soil Sampling/Characterization <br /> !_!Public Water System <br /> If different from Owner: Water System Name Contad Name or Phone Number <br /> TYPE OF WORK •)Chew Well i i Replacement Well rl Well Alteration/Modification P Other <br /> Monitoring Well(s) #of wells rl Soil Boring(s) #of bonne" !i Geotechnical Met bunngs <br /> Out-Of-Service Well i I Out-Of-Service Well Renewal f i Cross-Connection Repair <br /> U New Pump n Pump Replacement II Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method(Mud Rotary C Air Rotary Auger �'Cable Tool Push Point C! Other <br /> Proposed Well Depth 0 ft 6ccavation__La_in diameter -i Open Bottom . Gravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched n Steel ❑Plastic I i Stainless Steel :'I Other <br /> Grout Seal Depth III ft i i Neat Cement(94 Ib bag/5-10 gal wafer) Sand Cement sack mixl7 gal water <br /> Pentonite(20%solids) Other <br /> Grout Placement Method I 4Pumped I Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i!Driller Ii Pump Contractor i i Other <br /> I I Concrete Pedestal r iDimensions:Width ft Length ft Thick in I i Christy Box i I Stove Pipe <br /> PUMP ::Submersible)i 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIl� H UR ADVANCE NOTICE REQUIRED FOR'INiSP C/TIONS-PLEASE CALL(209)953-,7f697 <br /> SIGNED TITLE D!/1 1�� r DATE <br /> _ pgyMF <br /> FcF��F r <br /> p O <br /> NC <br /> Cq�T�N�Y <br /> PARTMENT USE ONLY �/J M�cNT <br /> Application Accepted By Date `/' ��- yy Area L�� Employee ID#�0 n/ <br /> Grout Inspection By Date y (_ _I_I_g SPECIAL W@II Permit <br /> Pump Inspection By Date T' WAIVER Received <br /> Soil Boring 1 spection By ++ Date Constructed Well Depth J H <br /> COMMENTS (-j jCCk i.l - { <br /> PE SC Received Checld# Amount a Permit/ Invoice# Well ID# <br /> Codes Into ash Remitted Service R est# <br /> G U .t!/ <br /> 3 14Ir 6f <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />