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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 XPIRES.1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ow 1k CITY/ZIP m <br /> CROSS STREET PN 00�— ! - PARCEL SIZE o-� LAND USE APIPLICATION# A <br /> OWNER NAME PHONE ! m <br /> OWNER ADDRESS P QVIT& CITY/STATE/ZIP <br /> CONTRACTOR /n� NE <br /> CONTRACTOR ADDRESSLcz� yr CITY/STATE/ZIP <br /> SUBCONTRACTOR PHON <br /> SUBCONTRACT ADDRESS CI STATE/ZIP <br /> LICENSE C 57 L l C-61 1 D-09 ❑ Other NUMBER EXPIRATION DATE <br /> 0— =I=-=4 <br /> DOMESTIC LL AMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural U Industrial I I Water Quality Monitoring LI 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 i I Well Alteration/Modification ❑ Other <br /> #of borings #of b rings <br /> ❑ Monitoring Well(s) #of wells Ll Soil Boring(s) 11 Geotechnical ���� <br /> ❑ Out-Of-ServicPump <br /> I ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair �A, <br /> C1 New Pum Re lacement ❑ Pum Repair ❑ Raise Well Casing +V <br /> WELL CONSTRUCTION ,9 n <br /> Drilling Method U Mud Rotary ❑ Air Rotary Li Auger U Cable Tool Ll Push Point L] Other "`fir <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size m dia <br /> Li Conductor Casing in diameter / Conductor Casing Depth ft H��F��NVjR�j CpUN <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I I Steel LI Plastic ❑ Stainless Steel I 1 OtTi�rT ENMTgI <br /> Grout Seal Depth ft LI Neat Cement(94 Ib bag/5-10 gal water) Ll Sand Cement sack mix/7Kg�rw. r <br /> I I Bentonite(20%solids) ❑ Other <br /> Grout Placement Method U Pumped ❑ Free Fall U Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By LI Driller ❑ Pump Contractor [I Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level% ft <br /> I HEREBY CE IFY 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 PENSATION LA S. <br /> NI 24 T REQUIRED F SPNS - PLEASE CALL (209) 9 3-7 997 <br /> SIGNED TITLE 7 11A DAT,EtE 6 <br /> IF <br /> I'A <br /> D ATMENT SE ONLY <br /> Application Accepted By � e -7) t Area Employee ID# <br /> Grout Inspection By ��,� ,,`` Date Ll SPECIAL Well Permit <br /> rT <br /> Pump Inspection By u\; wws n6 � Date Qty b l� kilo\ I-1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> od Info By,, Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />