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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 WIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ,C1/f/ oSDI/ Crtv21P w/7,^} , C" ,33 N <br /> m <br /> (� D <br /> CROSS STREET f APN I `�— -7 —0�0 PARCEL SIZE'l r� LAND USE APPLICATION# A <br /> OWNER NAME PHONE in <br /> OWNER ADDRESSCITY/STATE21P <br /> CONTRACTOR HONE <br /> chlf <br /> CONTRACTOR ADDRESS, / rr I � t�(J� CfrY/STATE/7JP k S�jw"^ <br /> SUBCONTRACTOR V `^� f n'/� .I PHONE <br /> 1 W >(` o <br /> SUBCONTRACTOR ADDRESS )10- K > D/ CrrYfST—=104- <br /> ATEIZIP l ✓z' <br /> LICENSE W C-57 L C-61 ❑D-09 n Other NUMBER W O EXPIRATION DATE 02,0-D <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)7 Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural L Industrial U Water Quality Monitoring 4 Soil Sampling/Characterization <br /> 7 Public Water System <br /> M different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well ❑Replacement Well C Well Alteration/Modification ❑Other <br /> L Monitoring Well(s) #of wells C Soil Boring(s) #of borings V Geotechnical #of bodngs <br /> 7 Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 7 New Pum -1 Pump Replacement D Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION t n <br /> Drilling Method 4 Mud Rotary�1 n Air Rotary yi Auger Cable Tool -1 Push Point n Other ^� <br /> Proposed Well Depth E Sy ft Excavation in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter � ��T <br /> Conductor Casing in diameter / Conductor Casing Depth ft / �� <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 7 L Steel L Plastic 7 Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(941b bag/5-10 gal water) C Sand Cement sack mi water <br /> Bentonite(20%solids) 0 Other `7O I? <br /> Grout Placement Method dPumped 7 Free Fall 7 Other ❑Retardant/Accelerator(name) / 7ivC, aJT <br /> PEDESTAL Installed By i I Driller i Pump Contractor I Other MFT <br /> Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe /t1 <br /> PUMP Submersibles Turbine n Other HP Pump Set ft Standing Water Level <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE <br /> /CALL(209)L95 -769 <br /> y <br /> SIGNED `-'7/U` -%b TITLE d '/ rl DATE <br /> �A TMENT U O LY <br /> Application Accepted ByIq <br /> Date U Area Employee 1D <br /> Grout Inspection By DateIll A17 ❑ SPECIAL Well 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 Permit/Codes Info Cash miffed Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 �7 D WELL/PUMP PERMIT <br />