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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 I CITY/ZIP <br /> n <br /> CROSS STREET API --19 PARCEL SIZE L // LAND USE APPLICATION <br /> # 0 <br /> OWNER NAME �T PHONE 0q-qLa <br /> ltrOWNER ADDRESS CITY/STATE/ZI <br /> CONTRACTORAll /V JA 0 11 hirl- MIZU Ll <br /> PHONE�� 2zm <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR A ZA PHONE <br /> SUBCONTRAC R ADDRESS ITY/STATE/ZIP / <br /> LICENSE C-57 1 C-61 ❑ D-09 LlOthef NUMBER EXPIRATION DATE ✓ <br /> DOMESTI WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) 1 , Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial U Water Quality Monitoring U 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 LI Replacement Well I_I Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service W II 11 Out-Of-Service Well Renewal Li Cross-Connection Repair <br /> LI New Pum I Pum Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ 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 Li Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft 11 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) a Other <br /> Grout Placement Method L I Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I Pump Contractor [I Other <br /> ❑ Concrete Pedestal I]Dimensions:Width ft Length ft Thick in ❑ Christy Box Li 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 /> I IM U VA CE NOTICE REQUIRED FO INSP IONS - PLEASE CALL (209!q/2797 <br /> SIGNED TITLE DATE <br /> 17 <br /> Al <br /> / C <br /> Ir <br /> T D NAL <br /> T <br /> DE ARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID#4WL <br /> Grout Inspection By Date C1 SPECIAL Well Permit <br /> Pump Inspection By �� X2344�c��9Jp qf� Date �U \D 'tD _1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck# Amount Permit/ <br /> o s Info B Cash R mitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />