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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 J�.�V �1V�Iritia". /`{Y lir CITY/ZIP L�4' �/ �r L, m <br /> CROSS STREET C•-4-IIJ APN PARCEL SIZE "TLAND USE APPLICATION# rn <br /> A <br /> C� �`tJ N <br /> OWNER NAME S' / I //` 8✓11a, �n�`� / PHONE g 7// <br /> OWNER ADDRESS h Y �t t' OZ i ITY/STATE/ZIP L <br /> CONTRACTOR �UC 1 I ✓ ��� PHONE . <br /> CONTRACTOR ADDRESS ` ' 04 CITY/STATE/ZIP 4 X 11/ (JI <br /> SUBCONTRACTOR Sa11^ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 11 Other NUMBER /�� <br /> /` EXPIRATION DATE <br /> DOMESTIC WELL.SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 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 Geotechnical of #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair Aw <br /> ❑ New Pum ❑ Pum Replacement ❑ Pum Repair ❑ Raise Well CasingPAY <br /> WELL CONSTRUCTION ECE1V <br /> MR <br /> Drilling Method 11 Mud Rotary ❑ Air Rotary Auger 11 Cable Tool LI Push Point Ll Other E® <br /> Proposed Well Depth ) ft Excavation lk�- in diameter 1_I Open Bottom ❑ Gravel Pack/Gravel SizPR n�20Weter <br /> Ll Conductor Casing in diameter / Conductor Casing Depth ft CU�y <br /> SAN J q <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel g UfN C <br /> Grout Seal Depth ft )a Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement HF-ALrH�c)b I water <br /> ❑ Bentonite(20%solids) CI Other Nr <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I l Pump Contractor 11 Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine I I 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 /> MIN U x48 HOURME NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> t ' ATE SIGNED� TITLEJLtDfi <br /> V ! <br /> L f I 1 <br /> '&E /RT USE ONLY /� /� <br /> Application Accepted By Date Area vo � Employee ID#_�& i <br /> Grout Inspection By Date 1-1 SPECIAL Well Permit <br /> Pump Inspection By Date L1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedec Amount Permit/ <br /> odes Info ash em'tted Date Service Request# Invoice# Well ID# <br /> 7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />