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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 CALL209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS CITY/ZIP m <br /> CROSS STREET APN �(1 PARCEL SIZE AND USE APPLICATION# A <br /> OWNER NAME �^ PHONE�(J—/T��CJ o? <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHON <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR A PHONE <br /> SUBCONTRACT ADDRESS CI Y/STATE/ZIP <br /> LICENSE 57 ElC-61 11D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEDomestic/Private ❑ Irrigation/Agricultural 11Industrial LlWater Quality Monitoring LiSoil Sampling/Characterization <br /> ❑ ublic 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 /> #of borings b n <br /> El Monitoring Well(s) #of wells [I Soil Boring(s) 11 Geotechnical <br /> T <br /> ❑ Out-Of-ServicW II 11 Out-Of-Service Well Renewal ❑ Cross-Connection Repair Cciveo <br /> [I New Pum Pum Replacement F1 PumRe air Raise Well CasingIt <br /> WELL CONSTRUCTION 2 2019 <br /> Drilling Method F1 Mud Rotary 11 Air Rotary LI Auger ❑ Cable Tool ❑ Push Point ❑ Other �J J <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom [I Gravel Pack/Gravel 5fm4ie 1RON� ?Xlqler <br /> LlConductor Casing in diameter / Conductor Casing Depth ft EPARrMENT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched [I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft I I Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 11 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Il 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 11 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 ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKE MPENSATION LAWS. <br /> IN 4 IC REQUIRED FO i PECTIONS -PLEASE CALL (209 ?01� <br /> SIGNED TITLE DATE <br /> 7 TUs <br /> / P "RTMENT SE NLY <br /> Application Accepted By Date Z 7/ Area Employee ID#4zf, <br /> Grout Inspection By rr ((11 Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received rChecK# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B emitted Service Request# <br /> c� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />