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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 L;ALLLUbI`J0.5-1 bt1 f FUht INSF°LG I IUNb CArlr[CJ I i tAM r'KVIVI UA I M Iaoumu <br />JOB ADDRESS ,����)) CITY/ZIP <br />CROSS STREET ( Q/Ip ROAN APN � �%�/� l PARCEL SIZE _LAND USE APPLICATION/#_ �2 <br />OWNER NAME PHONE Zoy Cy-4Or 30A <br />OWNER ADDRESS y a A,14 CITY/STATE/ZI <br />CONTRACTORDDI GrLn W`�/r PHONE✓ ! ir�l ��/JKf^/ Oma/ <br />CONTRACTOR ADDRESS 2-11D WAcm <br />`cm Zt7GL C <br />CITY/STATE/ZIP ✓-b(,kky� 1 i L1_/1 /✓���i <br />SUBCONTRACTOR PHONE A Z14 <br />SUBCONTRACTOR ADDRESS CITY/STAT/E,/,ZIP <br />LICENSE C-57 ❑ C-61 El D-09 [I Other NUMBER 41 YF?/�P113112-61? <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) i Dibromochloropropane (4392) -1 Arsenic (4393) <br />NTENDED USE 7 Domestic/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 />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump ' (Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I1 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller J Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP XSubmersibleF7 Turbine ❑ Other HP 12 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 />WORKERhI <br />OMPENSATION LAWS. <br />1 M 8 HO - VANCE NOTICE REQUIRED FOR I SPECTIO, IS - PLEASE CALL (209) 3-77697 <br />SIGNED TITLE/,�%_ DATE _! `� <br />DE ARTMENT U/ E/ONLY <br />Application Accepted By AA <br />c Date <br />Grout Inspection By Date <br />Pump Inspection By ��� ��+`� Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Lklaq Employee ID#� <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Permit/Codes Info B Cash Remitted Date Service Request # Invoice # Well ID# <br />I -I W DO 0 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />T <br />-a <br />M <br />D <br />0 <br />v <br />m <br />m <br />N <br />