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"'Run <br /> r ��� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDAB PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> `_ <br /> JOB ADDRES CITY/ZIP Sc'r`7yN ci S m <br /> �f� D <br /> CROSS STREET APN "7/ PARCEL SIZE/ r LAND USE APPLICATION# O <br /> m <br /> m <br /> OWNER NAME v � HONE /� N <br /> OWNER ADDRESS /� f CITY/STATE/ZIP `oqW <br /> CONTRACTOR PH NE [J <br /> CONTRACTOR ADDRESSCITY/STATE/ZIP <br /> SUBCONTRACTOR P ONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ilo C-57 ❑ C-61 ❑ D-09 I 1 Other NUMBE EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural it Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Cha rization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone N <br /> qTft <br /> TYPE OF WORK K New Well ❑ Replacement Well LI Well Alteration/Modification ❑ Other rkD <br /> Li Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical bo Ings <br /> ltlkOut-Of-Service Well El Out-Of-Service Well Renewal ❑ Cross-Connection Repai�4Nj X018 <br /> 11 New Pum Pum Replacement f I Pum Repair F1 Raise Well Casin OV 46--N <br /> WELL CONSTRUCTION hl pEP ENT,e� <br /> Drilling MethodMud RotatK ry E Air Rotary ❑ Auger (ICable Tool El Push Point 11 Other ARTMFN <br /> roposed Well Depth �M" ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size ` S! {'in diameter <br /> i <br /> ell Casing Diameter' <br /> Thickness/Gauge/ASTM Schad 41,55 2,00 11 Steel Plastic 11 Stainless Steel El Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement�0.� sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> rout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller rump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length___�3 —ft Thick of in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible Turbine ❑ Other HP_6�O Pump Set ft Standing Water Level /ate 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI U HOUR ADVANCE NOTICE REQUIRED FOR INSPECTI NS -PLEASE CALL (209) 9553-7697 <br /> SIGNED TITLE DATE 7 - <br /> IML- r& t <br /> i' <br /> r , <br /> 1,40 <br /> r <br /> Fr <br /> I; P RTMENT USE ONLf�Y <br /> Date CJ Area Employee ID# <br /> Application Accepted By <br /> Grout Inspection By Date C] SPECIAL Well Permit <br /> Pump Inspection By`� � (,IrtJ[�O fa4y X11 Date J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> OMMENTS <br /> PE SC Received C Che Amount Permit/ <br /> Coe fo B as Remitted Date Service Request# Invoice# Well ID# <br /> &C P > <br /> Ott ZSyV=:_ ZZ. Z(Q lF 111P 0oll <br /> �v /- .- - P <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />