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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 /> Ln <br /> JOB ADDRESS CITY/ZIP SC[j0� m <br /> D <br /> CROSS STREET W. A PN Zj 0=-O(,, PARCEL SIZE _LAND USE APPLICATION# p <br /> ^S arm m <br /> OWNER NAME � X � � PHONE 9S S— Ly 1 `i <br /> OWNER ADDRESS l V CITY/STATE/ZIPe 6C a b(�1. <br /> CONTRACTOR S PHONE.G,yS_L57—1 1 / <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP 11 )OdW 1 Q 1 QPT Q1��30 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER Z5o EXPIRATION DATES 3 lJ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial 1-1 Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> ot <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11Monitoring 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 /> I New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary 11Air Rotary 11Auger ElCable Tool f_l Push Point LlOther <br /> Proposed Well epth 40 0 ft Excavatio in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing -21 in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter tw in Thickness/Gauge/ASTM Schedl 11 Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_50 _ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I 1 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) LlOther <br /> Grout Placement ethod XPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ DrillerPump Contractor F1Other <br /> I--] Concrete Pedestal ❑Di ensions:Width ft Length_ ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible[I Turbine ❑ 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 COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIR O `SP/ECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED ' ITLE V �� DATE IQ <br /> T <br /> Q /I,,.. <br /> T M N <br /> T N <br /> EPRTMENTUSE ONLY 4qq <br /> Application Accepted By Date V O 1 Area _ Employee ID# <br /> Grout Inspection By e-09 -- Date / 9 ❑ SPECIAL WBII Permit <br /> Pump Inspection By Date U WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> CO MENTSt/ Caa�✓r' es�b ��.i 6srer �� SCL ��.raY/� /0 3 A41-V <br /> a <br /> PE Sc Received Amount Date Permit] Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />