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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 IfO iJeA VE CITY/ZIP S S C-0 m <br /> ry ^ I D <br /> CROSS STREET V� 1/I/a it�fi APN 13:304L PARCEL SIZEd#S3 LAND USE APPLICATION# A <br /> m <br /> OWNERNAME ti PHONE w <br /> OWNER ADDRESS at I U A U U CITY/STATE/ZJP }K ni SL <br /> CONTRACTOR 6�{� 1�.I�{ PHONE rV —1 L� <br /> CONTRACTOR ADDRESS ?00 �V1'�F4' f f'� S�Iw It3CITY/STATE/ZIP �L 11 JQ�DV <br /> SUBCONTRACTORPHONE O(' '�/1� (� y <br /> SUBCONTRACTOR ADDRESS L � ✓�� CITY/STATEE�/Z�IP r_s. 941. J' C✓1 l J <br /> LICENSE 4 C-57 El C-61 ❑D-09 ❑Other NUMBER Z"O ( EXPIRATION DATE Qt' <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE D Domestic/Private ❑Irrigation/Agricultural D Industrial D Water Quality Monitoring 41 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If mRerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well ❑Replacement Well D Well Alteration/Modification ❑Other <br /> D Monitoring Well(s) #of wells ❑Soil Boring(s) a or borings 4f Geotechnical of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal 'Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement D Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method d/Mudtary ❑Air Rotary ❑Auger ❑Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth SOft Excavation in diameter Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad - Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft 4 Neat Cement(94 lb bagl5-10 gal water) ❑Sand Cement sack mixf7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method 4 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller D Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length it Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set it 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 /> /M NI UMAu•OUR ADVANCE NOTICE REQUIRED MAIN PLEASE CALL(209 &-7697 <br /> SIGNED (- //7 TITLE 7 DATEoil V <br /> �^DEPARTMENT USE ONLY ✓1 <br /> Application Accepted By I / v Date I U-/ Area I /S mployee ID# 0 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 1! WAIVER Received <br /> Sail Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request W <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />