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WELL/PUMP PERMIT <br /> / SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3k20 <br /> NON-REFUNDABLE PERMIT CALL 209 53- 697 FOR INSPECTIONS EXPIRES 7 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP TKOA1//\/ &A/ t� <br /> �(J1 D <br /> CROSS STREET APN I PARCEL SIZE(�1 - W LAND USAA�PPL�ICNm �OWNER NAME y/// ONE ey,+ p <br /> OWNERADDRESS Rp- v CITY/STATE/ZIP 1 1 7 C l <br /> CONTRACTOR M13 mil VOW PHONE A I IftwqWr V, <br /> J ( V <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR / PHON <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ly'C-57 -i C-61 U D-09 L Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE estic/Private 1 Irrigation/Agricultural I Industrial I i Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If dlflarent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK u ew Well Replacement Well ,Well Alteration/Modification n Other <br /> E Monitoring Well(s) #of wells 7 Soil Boring(s) #of bonngs L Geotechnical #of Ings <br /> O Well -1Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pum L Pum Re lacement D Pum Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary ❑Air Rotary I I Auger i I Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom J Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad L Steel -1 Plastic r Stainless Steel r Other <br /> Grout Seal Depth ft 7 Neat Cement(94/b bag/5-10 gal water) J Sand Cement sack mix/7 gal water <br /> T- Bentonite(20%solids) n Other <br /> Grout Placement Method -i Pumped I I Free FK I Other L Retardant/Accelerator(name) <br /> PEDESTAL Ins d By ❑Driller vPump Contract Other <br /> oncrete PedestallIDimensions:Width ft Length ft Thick in Christy Box n Stove Pipe <br /> PUMP ubmersibleD Turbine IOther. 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED / TITLE DATE <br /> E <br /> C MENS' <br /> VIED <br /> B I RA 07 1019 <br /> 4-1 AQuiN CO(jNTy <br /> ZAL <br /> ,RONM <br /> N DEPART NT <br /> P TMENT USE NLY <br /> Application Accepted By ate '711Area Employee ID#)� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection Byf�Q F111 �YJ�Q Date b Z WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receive Check#/ Amount Date Permit/ Invoice# Well[DO <br /> codes Info Cash Remitted Service Re nest# <br /> EHD 43-06 revised 4/14/18 7 7-7^-,7,-26, WELL/PUMP PERMIT <br />