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sh <br /> 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�71 YEAR FROM DATE ISSUED <br /> OB ADDRESS I ,' k-I ` CITYIZIP Lck f AY-I/,0 q/�3 'Cn <br /> OSS STREET API' 1 1 3 L/ (� PARCEL SIZ4 04 LAND USE APPLICATION# p <br /> m <br /> O ER NAME PHONE N <br /> O ERADDRESS �� ��y{�'y�, CITY/STATE/ZIP <br /> CONTRACTOR ;dell I✓� <br /> _� I PHONE <br /> COAj NTRACTOR <br /> CONTRACTOR ADDRESS to Ir 1 n/• NO CITY/STATE/ZIP <br /> � <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 71 U'7yry^1 <br /> �r 7 CITY/STATE/ZIP fi+ �^y O <br /> LICENSE i C-57 ❑C-61 ❑D-09 ❑Other NUMBER� EXPIRATION DATE V <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE D Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring I Soil Sampling/Characterization <br /> ❑Public Water System <br /> If tliHerent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well D Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells D Soil Boring(s) i#ofborings Geotechnical it of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method jMud Rotary D Air Rotary (/Auger ❑Cable Tool ❑Push Paint ❑ Other <br /> Proposed Well Depth � ()ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller D Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width it Length ft Thick in ❑Christy Box D Stove Pipe <br /> PUMP ❑Submersible❑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 /> IMU 48 U VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> -PLEASE C <br /> LEASECALL(209) 5Z3-7697 <br /> SIGNED TITLE L.=/rg//�C�l�/ DATE J C <br /> 170 1 <br /> T <br /> Z_ 7p JIAI <br /> PA TMENT USE NLY <br /> Application Accepted By� Date Area Employee ID#7- <br /> Grout Inspection By Date ❑ SPECIAL ell Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B C sh Remitted Service Re uest# <br /> sI 119 <br /> EHD 43-06 revised 4/14/18 <br /> WELL/PUMP PERMIT <br />