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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 />JOB ADDRESS —/ CITY/ZIP <br />CROSS STREET APN 11 0 /� PARCEL SIZE l / SLAND USE APPLICATION # <br />OWNER NAME PHONE2yq .430- E�� <br />OWNER ADDRESS Q CITY/STATE/ZI <br />CONTRACTOR LJ PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR A �I1 PHONE <br />SUBCONTRA79-57 <br />ADDRESS C Y/ST TE/ZIP <br />LICENSE D C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />DOMESTIC ELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 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 />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />0 New Pump Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched l 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) 11 Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 0 Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />CI Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ij 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 />WORKERB-COMPENSATION LAWS. <br />MI IMUM 4 {"L(��j[ NCE NOTICE <br />NIO)T_ICE REQUIRED F R INSPE TIONS - PLEASE CALL (209) 953-769 l <br />SIGNED �' �F l 11 ulJll�'N, I(/V v TITL DATE <br />c <br />D PARTMEN/T USE NLY <br />Application Accepted By00�Date [ Area ' 6 Employee ID# <br />ZL <br />Grout Inspection By Date 11 (� D SPECIAL Well Permit <br />Pump Inspection By Date R, D WAIVER Received <br />Soil Boring I <br />COMMENTS / <br />Date <br />Constructed Well Depth <br />ft <br />rrL <br />m <br />D <br />v <br />v <br />M <br />m <br />Cn <br />ur <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Permit/ <br />emitted Date S rvice Request # Invoice # Well ID# <br />S <br />% S <br />EHD 43-06 8/01/16 <br />WELL /PUMP PERMIT <br />