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1 <br /> WELL/PUMP PERMITw', ihC �(r-Wd <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 9602 (209)4Ga <br /> NON-REFUNDABLE PERMIT CALL 2O9 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> 5 s fn <br /> JOB ADDRESS CITY/ZIP f/ m <br /> rn <br /> /�• D <br /> CROSS STREET I A P N _03 PARCEL SIZE _LAND USE APPLICATION# z <br /> OWNER NAME � PHONE;2)q— 7&-0700 <br /> �{� y <br /> OWNER ADDRESS CITY/STATE/ZIPS <br /> 1 <br /> CONTRACTOR PHONE C_L/`�/ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP LO <br /> 951_2Z6_ <br /> SUBCONTRACTOR A PHONE <br /> SUBCONTRACTOR ADDRESS CV/STATE/ZIP <br /> LICENSE VC-57 11 C-61 I I D-09 ❑ Other NUMBER EXPIRATION DATE ✓ ^� <br /> DOMESTIC WELL SAMPLING: 1-I General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)L_1 Arsenic(4393) <br /> INTENDED USE omestic/Private I I Irrigation/Agricultural U Industrial I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Ll Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1 I New Well I I Replacement Well LI Well Alteration/Modification Ll Other <br /> I I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 1 Out-Of-Service W II ❑ Out-Of-Service Well Renewal 1-1Cross-ConnectionRepair <br /> New Pum Pum Replacement I 1 Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 11 Mud Rotary I I Air Rotary 11 Auger 11 Cable Tool I I Push Point I I Other <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic IJ Stainless Steel 1_I Other <br /> Grout Seal Depth ft LI Neat Cement(94/b bag/5-10 gal water) 1.1 Sand Cement sack mix/7 gal water <br /> I I Bentonite(20%solids) 1_1 Other <br /> Grout Placement Method I 1 Pumped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I I Pump Contractor ❑ Other <br /> I Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box LI Stove Pipe <br /> PUMP Submersiblel I Turbine I I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CEF4iFY 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 C MPENSATION LAWS. <br /> MI UDAA171%111 UDV NCE NOTI E REQUIRED FO INSPEC ONS -PLEASE CALL (209) 953-769 <br /> SIGNED TITLEDATE � <br /> 71 <br /> �r <br /> 0 <br /> / o c <br /> F T <br /> N <br /> E ARTMENT USE 9NLY <br /> l <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date pp�� q r_ F1PECIAL Well Permit <br /> Pump Inspection By 1�1N ���r,J��V� Date N k A �1 I WDA CI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Permit/ <br /> o s Info B ash miffed Date Service a uest# Invoice# Well ID# <br /> 5o a r <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />