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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 /E�XPJ ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS :L j-��� CITY/ZIP <br /> `> G L:i� r� ' ��� 7- m <br /> a D <br /> CROSS STREET L'9 t--� APN (/ PARCEL SIZE `/ LAND USE APPLICATION# 0 <br /> OWNER NAME Ih L i' PHONE — 0 / co <br /> c? <br /> OWNER ADDRESS %t LY CITY/STATE/ZIP <br /> CONTRACTOR VPHONE <br /> )) 7 <br /> CONTRACTOR ADDRESS �✓ CITY/STATE/ZIP <br /> SUBCONTRACTOR e� ' C�� �c.� L PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ><5157 11 C-61 D-09 Other NUMBER �t EXPIRATION DATE " <br /> '1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial I Water Quality Monitoring Soil Sampling/Characterization <br /> u Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well % Replacement Well CI Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells [-I Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump Pump Replacement f 1 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method%.,j1,Pud Rotary Air Rotary Auger J Cable Tool I Push Point Other <br /> Proposed Well Depth :o ft Excavation �— in diameter I 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—7_0D Steel Plastic IStainless Steel Other <br /> Grout Seal Depth /',��} ft I Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) i i Other_ <br /> Grout Placement Method Pumped i I Free Fall Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By W-Driller Pump Contracto? I I Other <br /> Concrete Pedestal !Dimensions:Width ft Length 01 ft Thick in I I Christy Box ❑ Stove Pipe <br /> PUMP ^<Submersiblei l Turbine I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> MINIMUM 48 HOUR///��r.►!VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) X9/53-7697 <br /> SIGNED . /.iu11 TITLE ^,�LiL�yt DATE <br /> G <br /> � N <br /> N / NC01,A <br /> p Tq <br /> T <br /> i <br /> EPA RTMENT US ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By ✓ Date I V'kSPEC AL Well Permit <br /> Pump Inspection By ti V Date I 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 /> Codels Info B Cash Remitted Service Request# <br /> I: WS <br /> d SL W 'l(-P <br /> EHD43-06 8101/16 WELL/PUMP PERMIT <br />