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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 CA 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS CITY/ZIP WkftS m <br /> � D <br /> CROSS STREET APN PARCEL SIZE / ' / LAND USE APPLICATION# <br /> ' T _ v k m <br /> Cn <br /> OWNER NAME HONE u? <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> ju& <br /> CONTRACTOR PHONE q_-31 3alD <br /> Al <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR ft 44 PHONE <br /> SUBCONTRA�TR ADDRESS CI Y/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC ELLS MPLINc: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE mestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ 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 ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ ut-Of-Service II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair pjgYM <br /> New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUC O <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point LI Other nr, 4 <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel -"" 0". inA �eter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth It H�AF/IV/� ( H C 'o <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched LI Steel ❑ Plastic ❑ Stainless Steel ZTO ON O� <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement SaaTo water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall LI Other i i Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Leng ft Thick in I I Christy Box 11Stove Pipe <br /> 11 , <br /> PUMP Submersible❑ Turbine F1Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CER I 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 /> WORKERS COMPENSATION LAWS. <br /> MINIM U NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953 647 <br /> SIGNED i j�� TITLE <br /> ��n ` DATE <br /> ti <br /> DE ARTMENT <br /> USE VNLY <br /> Application Accepted By Date Z Area 41 Employee ID#� <br /> Grout Inspection By Date 0 ❑ SPECIAL Well Permit <br /> Pump Inspection By ��'� =� is��l� �k\�M Date f 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Che Amount Permit/ <br /> Co Info ash emitted Date Service Request# Invoice# Well ID# <br /> EHD43-06 8/01/16 '� ,�+' ��—/� WELL/PUMP PERMIT <br />