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��-n� <br /> WELL/PUMP PERMIT ��1I <br /> UUM <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 (` (E�XPwIREE1S1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS qWo TPAA n nCfrYZP 'G^,C.K4��L//1 ✓ v m <br /> CROSS STREET 10A+-14a- I a-7b APN - PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME I r 11 j^ A. PHONE oy+, <br /> OWNER ADDRESS ( L CITYISTATEZP 4 n <br /> CONTRACTOR PHON ` <br /> CONTRACTOR ADDRESS ,— CrrYISTATE(ZlP I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTYISTATEZP <br /> LICENSE I C-57 C-61 D-09 Other NUMBER 4Q 9 0 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: 1 General MinerallColiform Bac eria(4391)C Dibromochloropropane(4392)1_ Arsenic(4393) <br /> IHTENDeD USE Domestic/Private Irrigation/Agricultural Lj Industrial Water Quality Monitoring I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well i Replacement Well i Well Alteration/Modification Other <br /> II MonitoringWell(s) #of wells ❑SoilBoring(s) #ofWngs Geotechnical #of borings <br /> Put-Of-Service Well L Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pum i I Pump Replacement i Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i Mud Rotary i Air Rotary I Auger Cable Tool -1 Push Point i Other <br /> Proposed Well Depth It Excavation in diameter ❑Open Bottom a Gravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad a Steel ❑Plastic rl Stainless Steel Il Other <br /> Grout Seal Depth It I i Neat Cement(94 111 bag/5-10 gal water) i i Sand Cement Sack mix/7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method I I Pumped i I Free Fall ❑Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed Byriller I Pump Contractor r Other <br /> I Concrete Pedestal (Dimensions:Width It Length ft Thick in a Christy Box I Stove Pipe <br /> PUMP Submersible)i Turbine I I Other HP Pump Set 040 It 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 WI THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO PE ATION WS. <br /> MI I 4 U ADVANCE NOTICE REQUIRED FOR NSPECTIONS-PLEASE CALL(209)953- 97 <br /> SIGNED TITLE � [ DATE <br /> P TMENT U E O LY <br /> � 9 <br /> Application Accepted By Date Area ` Employee ID# <br /> Grout Inspection By �__ Date I PECIAL Well Permit <br /> Pump Inspection By 6(�k t c�[Af`�f n Date , I I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Amount D to Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />