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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 /> N <br /> JOB ADDRESS CITY/ZIP m <br /> I D <br /> CROSS STREET Uhl 0 APN 1 O s/ PARCEL SIZE AND USE APPLICATION# <br /> -7041 m <br /> `= � y <br /> OWNER NAME PHON A � <br /> OWNER ADDRESS CITY _&� //STATE/ZIP 0_r_,(/ 1'].� <br /> 15 <br /> CONTRACTOR PHONE1�01 �� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACT ADDRESS C Y/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC VILL SAMPLING: I i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) ❑ Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number AA <br /> TYPE OF WORK [I New Well ❑ Replacement Well Li Weil Well Alteration/Modification Other <br /> ❑ ri <br /> Monitoring Well(s) #of wells ❑ g #of borings ❑ <br /> Soil Boring(s) Geotechnical r F'r <br /> [IOut-Of-Service II 11 Out-Of-Service Well Renewal Ll Cross-Connection Repair CF�V�O <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well CasingC <br /> WELL CONSTRUCTION 9 n <br /> Drilling Method 11 Mud Rotary 11 Air Rotary ❑ Auger ❑ Cable Tool El Push Point [I Other �JO ` 2019 <br /> Proposed Well Depth ft Excavation in diameter 11Open Bottom 11Gravel Pack/Gravel ICT r <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft '°'9RjtyF <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other NT <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 ❑ 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 <br /> Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERfiFY 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,QQMPENSATION LAWS. <br /> INI 4 NOTICE REQUIREDFO INSPE - PLEASE CALL (209) 95 X76 <br /> SIGNED TITLE AMA A u I DATE PU <br /> PA TMENT U E O LY <br /> Application Accepted By Date ' r Area Employee ID# <br /> Grout Inspection By t1 ` Date ❑ SPECIAL Well Permit <br /> Pump Inspection By jG l�V� \ Date ®� ©�Q 2D�c� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ,-Chq.Ck0 Amount Permit/ <br /> Cods Info B emitted Date Service Request# Invoice# Well ID# <br /> •22 I WPD 3`'I _ <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />