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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 J CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 <br /> JOB ADDRESS / �� / �� /1,/ CITY/ZIP E� / I � m <br /> C D <br /> CROSS STREET 'N O ARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME /`k�`/'� �/`�f� �� PHONE y <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR L� PHONE <br /> CONTRACTOR ADDRESS f—� �� h�f, CITY/STATE/ZIP <br /> SUBCONTRACTOR �� L� ^/r+S�� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> E/ <br /> /ZIP <br /> LICENSE &t-57 0-61 (1D-09 I I Other NUMBER 6f+ ! EXPIRATION DATE 7S� <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 4bomestic/PrivateJ(rrigation/Agricultural ❑ Industrial I t Water Quality Monitoring LiSoil Sampling/Chaill �or <br /> 11 Public Water Systteem <br /> If different from Owner: Water System Name Contact Name or Phone Num <br /> TYPE OF WORK,Clew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical o or <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair S BIN COTAR�N <br /> TYEONMEN'Atlew Pum F1 Pum Replacement F1 Pum Repair Raise Well Casing <br /> WELL CONSTR &TION ENT <br /> Drilling Method;II&ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I_; Push Point ❑ Other <br /> i <br /> Proposed Well Depth 'ft Excavation in diameter Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter If in Thickness/Gauge/ASTM Sched 10-4 ❑ Steel 101astic CI Stainless Steel ❑ Other <br /> Grout Seal DepthADft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ,;Oentonite(20%solids) ❑ Other <br /> Grout Placement Method umped (i Free Fall ❑ Other CI Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1VPump Contractor U Other <br /> ❑ Concrete Pedestal ❑ Imensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 44oubmersibleLl Turbine Cl Other HP_10 Pump Set Standing Water Level <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 /> MIN 5MCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9.53-N9 <br /> SIGNED — <br /> TITLE���!/; /'�"� DATE L <br /> u <br /> V 1 <br /> EP RTrrlEIN J C :, r2L <br /> Application Accepted By Date Area Employee ID#1 Py <br /> - � �-- <br /> Grout Inspection By '1 Date "10 ❑ SPECIAL Well Permit <br /> Pump Inspection By (^�I fInp cl L 0-x. I, Date I Jq ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 1) ?_rLU&t2► - <br /> PE Sc Received C She Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> S <br /> 2KSE2_3 _X7103 <br /> I <br /> EHD 43-06 8/31116 WELL/PUMP PERMIT <br />