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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON�J 974 ME <br /> NON-REFUNDABLE PERMIT CA L 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP m <br /> , <br /> � s-27o <br /> CROSS STREET APN ARCEL SIZE AND USE APPLICATION# A <br /> JI An /1 R m <br /> OWNER NAME PHONE-OW (� 7 y <br /> OWNER ADDRESS CITY/STATE/ZIP_& <br /> L✓C/!O <br /> CONTRACTORfNA& V?r2PHONE ��/1122Z . <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR A AA PHONE <br /> SUBCONTRACT R ADDRESS CI Y/ TATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER &V&- EXPIRATION DATE <br /> DOMESTIC LL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 1 Arsenic(4393) <br /> INTENDED USEomestic/Private 11 Irrigation/Agricultural _1Industrial I Water Quality Monitoring LlSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ElMonitoring Well(s) #of wells [ISoil Boring(s) #of borings ❑ Geotechnical <br /> ❑ Out-Of-Service W II ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION - 1 CUM <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other SAN.49AQUIN <br /> Col IKI, <br /> Proposed Well Depth ft Excavation in diameter H Open Bottom ❑ Gravel Pack/Gravel MEAL p� <br /> Hmeter <br /> 11 Conductor Casing in diameter / Conductor Casing Depth ft MENT <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I 1 Steel ❑ Plastic 11 Stainless Steel ❑ Other <br /> Grout Seal Depth ft I I Neat Cement(94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 1.1 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall F1 Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller f I Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ 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. 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 /> WORKER MPENSATION LAWS. <br /> IN 24 A NPENOTICE REQUIRED n <br /> PFdnONS - PLEASE CALL (MY `-z_697,l <br /> SIGNED TITLff" DATE <br /> JNU <br /> EP T M E N T <br /> �/U <br /> ENLY <br /> Application Accepted By Date , Area Employee ID# <br /> Grout Inspection By Date (( ( L7 SPECIAL Well Permit <br /> Pump Inspection By NW's. Date y t 2 Z I Z b\C\ LI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Cgh=kW Amount Date Permit/ Invoice# Well ID# <br /> Co s Info Cash emitted Service Re ,,est# <br /> 5 <br /> EHD 43-06 6101/16 WELL/PUMP PERMIT <br />