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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-REFUNDAB C L 953- a FOR INSPECTIONS EXPIR S 1 JEFROM DATE ISSUED <br /> y <br /> JOB ADDRESS IL4CITY/ZIP In <br /> D <br /> CROSS STREE P ' CEL SIZE 19 <br /> AND SE APPLI TIO # o <br /> r► m <br /> OWNER NAME H <br /> OWNER ADDRE //�') C /STATE/ZIP <br /> CONTRACTOR _jer V1 ( / P <br /> CONTRACTOR ADDR S CITYISTATE/ZIP <br /> LU <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cl /STATE/ZIP t <br /> LICENSE -57 C C-61 f]0-09 E Other NUMBER EXPIRATION DAT ` <br /> DOMESTIC WELL SAMPLING:n General M ral/Coliform Bacteria(4391) Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE i Domestic/Private rrigation/Agricultural E Industrial Water Quality Monitoring _j Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ew Well Replacement Well C Well Alteration/Modification Other <br /> E Monitoring Well(s) #of wells C Soil Boring(s) #of borings Ei Geotechnical #ofbotings <br /> Out-Of-Service Well E Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pum -1 Pump Replacement n Pump Repair F Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary n Air Rotary n Auger n Cable Tool -1 Push Point 1 Other <br /> Proposed Well Depth �j 0A ft Excavation—i/�--In diameter L Open Bottom V Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter 7 Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad k It 7 Steel E Plastic -i Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(941b bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br /> Bentonite(zu ie solids) Other <br /> Grout Placement Method YPumped E Free Fall 7 Other _j Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller XPump Contractor i Other <br /> E Concrete Pedestal[]Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP �Submersible Turbine n 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. 1 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 /> M UM 48 FLOUR VYANCE NOTICE REQUIRED FOR I/NIPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNE TITLE DATE <br /> eci; <br /> DAfAfJE� <br /> QUI/y Cp <br /> T 'Ep I Tqt ry <br /> MENT <br /> D_X4AR-dM ENT USNLY <br /> r • <br /> Application Accepted Bylex Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER ReceiV d / <br /> Soil Boring Inspection By Date Constructed Well Depth I-L� ft <br /> COMMENTS <br /> PE SC Received h Amount Date PermiU Invoice# Well ID# <br /> o I ash R&nitted Service Request# <br /> 174 N <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />