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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 />NDN -REFUNDABLE PERMIT CALL 209 95 7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 14 21 <br />9 4W CITY/ZIPd2 7 <br />' CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />zz n <br />APN /)70 -1/0 - 2--1 PARCEL SIZE �v LAND USE APPLICATION # <br />PHHONEELn — 5 <br />CITY/STATE/ZIP 1 %� jvfw� qb22 <br />CONTRACTOR <br />P ONE ) L � l 3 `-1 <br />CONTRACTOR ADDRESS <br />N a CITY/STATE/ZIP tloj " _ v <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE -57 El C-61 El D-09 <br />CI / T TE/ZIP / <br />FJOther NUMBER EXPIRATION DATE 1-3j! <br />DOMESTIC ELL SAMPLING:' General Mineral/Coliform <br />Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USE 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 11 Geotechnical # of borings <br />Cl Out -Of -Service Vell ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump A Pump Replacement ❑ Pump Repair 1 I Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 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 f_i Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) I1 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal IDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine Fl 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 />WORKERS.QOMPENSATION LAWS. <br />IN UMM448 V NOTI REQUIRED FFR IINSP ONS -PLEASE CALL (209) 953-77697 <br />SIGNED /V Vl/Y DA/l /� TITLEY l DATE / / � 0 16 <br />EP RTMENT U E O LY nrALTH DEPARTMENT <br />Application Accepted By Date "Z_ Area Employee ID# <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By 1�1TwiJ tntl�llld�}11r1 QIP Datei2�� �i ii ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received 4hezw Amount <br />Codes Info By Cash Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Re uest # <br />++ ISgfly <br />I . --I ► QU3 0 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />