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s <br /> 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 EXPIRES 1 YEAR FROM <br /> �DATE <br /> IISSUED <br /> JOB ADDRESS ' CITY/ZIP ./�/�/ m <br /> D <br /> CROSS STREET APN 'j PARCEL SIZE ✓ LAND USE APPLICATION# 0 <br /> ( I m <br /> OWNER NAME \ /yON/E ` �) N <br /> OWNER ADDRESS / CITY/STATE/ZIP VV ` <br /> CONTRACTOR PHONE /�1// VV <br /> CONTRACTOR ADDRESSca <br /> C�jwCITY/STATE/ZI { C <br /> SUBCONTRACTOR 41 111 PHONE <br /> SUBCONTRACT R ADDRESS C Y/S ATE//ZIP <br /> LICENSE C-57 11C-61 11D-09 Li Other NUMBER ` EXPIRATION DATE <br /> DOMESTIC IWELL SAMPLING: I I General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) L Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Ll Soil 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 11 Soil Boring #of boringss) Ll Geotechnical �D <br /> 11 Out-Of-Service ell [I Out-Of-Service Well Renewal CI Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing AP <br /> WELL CONSTRUCTION <br /> %0 zuty <br /> Drilling Method [I Mud Rotary ❑ Air Rotary El Auger L] Cable Tool [I Push Point 11 Other yy : n?NU1N <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grave ISPALTHQ� 4&meter <br /> 11 Conductor Casing in diameter / Conductor Casing Depth ft MFNT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 1-1 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]M,COMPENSATION LAWS. <br /> M MO D ANS OTIC REQUIRED FOR ECT ONS - PLEASE CALL (209) 9 -7697 G, <br /> SIGNED TITLE DATEVV <br /> c <br /> EP RTMENT Usy O LY <br /> Application Accepted By IMPDate_ Area Employee ID#� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By � Date QK /f_QNA ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> ,igodsInfo s emitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />