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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 />NUN -REFUNDABLE PERMIT <br />JOB ADDRESS <br />Ail virw, <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR14VI II <br />CONTRACTOR ADDRESS(, <br />SUBCONTRACTOR <br />ADDRESS <br />�ffMWM!kjhk1ZL:]'ll <br />my, . - WA WITI <br />ir/ <br />NL , MEI/I � / <br />LICENSE 12-57 ❑ C-61 ❑ D-09 ❑ Other <br />NS (MI-IRtb 'I YEAR FROM DATE ISSUED <br />_LAND USE APPLICATION #� <br />A PHONE w {-4�( �1r l 5Z / <br />CITY/STATE/ZIP U% ALI-11 L -T33 /�:J��I!J/ --Z2 <br />SONP <br />E��� <br />CITY/STATE/ZIPY *yI Ci <br />PHONE n 1 ///V) <br />EXPIRATION <br />DOMESTIC WELL SAM LING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 Arsenic (4393) <br />NTENDED USE omestic/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 Lj Geotechnical # of borings <br />❑ Out-Of-ServiceII [I Out -Of -Service Well Renewal 11 Cross -Connection Repair <br />ElNew Pump VPUmp Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool n 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 I I Steel [ I Plastic U Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other r I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller n Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible[] Turbine 1_1 Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTI 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 />WORKE COMPENSATION LAWS. <br />MI I UM 48 6U DVANCE NOTI REQUIRED F�Oj�§' INSPE T /- PLEASE CALL (209) ?13-7697 <br />SIGNED TITLE\A1 i DATE <br />* e <br />E P RTMENT USE C LY <br />Application Accepted By Date 7/ <br />Grout Inspection By ^ �y� Date <br />Pump Inspection By Date 1A <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />0 <br />0 <br />0 <br />rn <br />m <br />U) <br />in <br />--.'N/mENT <br />Area 41j411M Employee ID#j� <br />❑ SPECIAL Well Permit <br />[_] WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received ec Amount Permit/ <br />o s Info B Cash emitted Date Service Re uest # Invoice # Well ID# <br />)sgo4- L <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />