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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> \ JOB ADDRESS Z_� (i JE�AP CITY/ZIP C / m <br /> CROSS STREET APN w v D _ \! PARCEL SIZE LAND USE APPLICATION# A <br /> ca <br /> OWNER NAME 0 P ONE ) C1) <br /> rp <br /> OWNER ADDRESS CITY/STATE/ZIP �ITV"v <br /> CONTRACTOR �W 1 'S 1 PHONE <br /> CONTRACTOR ADDRESS 1 CITY/STATE/ZIP <br /> / <br /> SUBCONTRACTOR V ,C— (,LtG {`lr 7 ✓r ! r/Y <br /> IPHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIPJDd tJ. <br /> 1 <br /> LICENSE C-57 I I C-61 I I D-09 ❑ Other NUMBER EXPIRATION DATE — _ <br /> DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria(4391) -I Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE 77:Domestic/Private Irrigation/Agricultural I I Industrial I I Water Quality Monitoring J Soil Sampling/Characterization <br /> I1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >4z New Well I Replacement Well I I Well Alteration/Modification 1 Other <br /> 1 1 Monitoring Well(s) #of wells i I Soil Boring(s) #of borings ❑ Geotechnical #° E <br /> I Out-Of-Service Well I I Out-Of-Service Well Renewal I I Cross-Connection Repair JUL <br /> i New Pum I I Pum Replacement F1 Pump Repair LI Raise Well CasingSAN WELL CONSTRUCTION ` <br /> Drilling Method eT�Mud Rotary CI Air Rotary L Auger ❑ Cable Tool 1 Push Point I1 Other E I/ QAI'N CDUN <br /> Proposed Well DepthI kC� ft Excavation IaZV in diameter I I Open Bottom 11 Gravel Pack/Gravel Size <br /> I 1 Conductor_Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6- in Thickness/Gauge/ASTM Sched ;201LI I I Steel A Plastic ❑ Stainless Steel I I Other <br /> Grout Seal Depth 1013 ft 1 I Neat Cement(94 Ib bag/5-10 gal water) 11 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped I 1 Free Fall I-1 Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller *Pump Contractor ❑ Other <br /> I Concrete Pedestal I1 Dimensions:Width ft Length ft Thick in Ll Christy Box i I Stove Pipe <br /> PUMP Submersible 1 Turbine 1 I 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 /> CURREN ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE S OMPENSATION LAWS. <br /> lin, CE TICE REQUIRED FO NSPEC IONS -PLEASE CALL (209 90-7697 <br /> ,Ixft�SIGNED TITLE DATE <br /> 11 <br /> l <br /> CGF,G= N' <br /> O <br /> a <br /> t U <br /> A, AkY t/ <br /> fi e <br /> D ARTMENT WEO LY <br /> Application Accepted B10 <br /> y Date Areaell Employee ID# <br /> Grout Inspection By Date 26 1_I SPECIAL Well Permit <br /> i <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Datte Constructed Well Depth ft <br /> COMMENTS i <br /> lilt <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Byn Cash Remitted Service Request# <br /> 21 t <br /> W�G2, <br /> 045; L <br /> 00 N <br /> o i 6t <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />