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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS U CITY/ZIP m CROSS STREET APN I v PARCEL SIZE u LAND USE APPLICATION#jm v� OWNER NAME i(U)lA � 2J PHONE4 o OWNER ADDRESS / CITY/STATE/ZIP CONTRACTOR CJ V PHONE �`v CONTRACTOR ADDRESS i-- �CtC.�ft%1- r� CITY/STATE/ZIP �1L lA- "1(�� ✓�� SUBCONTRACTOR • PHONE r SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE _1�7 ❑ C-61 ❑ D-09 ❑ Other NUMBER � EXPIRATION DATE �v DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural I] Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection RepairA ew Pum ❑ Pum Replacement 11 Pump Repair F1 Raise Well CasingR 17 WELL CONSTRUCTION ,SqN Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other EN IRQU/N Cr)' Proposed Well Depth ft Excavation in diameter F1Open Bottom _F1Gravel Pack/Gravel SII Q 'pNTl/diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft FNT Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HPPump Set (, ft Standing Water Level ft e I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VjITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IMUM 48 OUR ADVANCE NOTICE REQUIRED Fj INSPECTIONS -PLEASE CALL (2091 3- 697 71 SIGNED TITLE 1 DATE DjcP RTMENT U E ONLY j Application Accepted By Date �� r Area ' Employee ID#. Grout Inspection By Date I t ❑ PECIAL Well Permit Pump Inspection Byy �J �"WN" l}� I� Date q10 V\ ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received ZIL05W Amount Permit/ Codes Info B Cas emitted Date Service Reguest# Invoice# Well ID# I°I 7 EHD 43-06 8/01116 WELL/PUMP PERMIT