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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 /> 5 mD� <br /> JOB ADDRESS S CITYLP <br /> APN tjCROSS STREETS Y/ � JO U PARCEL SIzr� AND USE PPLICATION# <br /> A <br /> OWNER NAME / <br /> OWNER ADDRESS l CITY/STATE/LP <br /> CONTRACTOR VIA PHONE <br /> CONTRACTOR ADDRESS CITY/STATE0P <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1 <br /> LICENSE X C-57 C-61 f 1 D-09 .f Other NUMBER 3 3 EXPIRATION DATE 7/J'/-)-a <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private :Irrigation/Agricultural :.I Industrial ❑Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK `(�New Well Replacement Well ❑Well Afteration/Modification ❑Other <br /> Monitoring Well(s) #of wells ❑Soil Boring(s) #of bedngs Geotechnical #of bodngs <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> )(NewPump I Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Y,Mud Rotary _I Air Rotary Auger ❑ Cable Tool Push Point ❑ Other <br /> Proposed Well Depth;L;75Excavation _in diameter C Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-+fes in Thickness/Gauge/ASTM Sched(dC_2!b� IAL Steel X Plastic I Stainless Steel 1 Other <br /> Grout Seal Depth� ft Neat Cement(94 Ib bag/5-10 gal water) x Sand Cement jb 3 sack mixl7 gal water <br /> Bentonite(20%solids) Other �A Yd � .� <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) IV <br /> r <br /> PEDESTAL Installed By Driller I Pump Contract Other � d <br /> Ik Concrete Pedestal LiDimensions Width ft Length It Thick in ❑Christy Box 1_I Stove Pipe <br /> PUMP YSubmersible .Turbine Other HP Pump Set ft Standing Water Level ft "10V 13 20118 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAtV JOA <br /> JOAQUIN COUNTY CURRENT AND ACTIVE(WITH THE SCAL CALIFORNIA CONTRACTORS STATETATE LAWS, AND RULES AND D LICENSE BOARD AND THAT I AM IN COMPLIANCE LATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE <br /> A41jp NVlf�pNM COUNTY <br /> WORKERS COMPENSATION�, U/Rt fADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 () LTN�E�AR SENT <br /> SIGNED / -J �l --""A'�ti TITLE Y i'z' r/Y�t DATE �S <br /> . PA TMENT SE ONLY <br /> Application Accepted By ate .12 <br /> WArea Employee ID#� <br /> Grout Inspection By Date SPECIA Well Permit <br /> Pump Inspection By Date2 l` C %- WAIVER Received <br /> Soil Boring inspection By Date C cted Villell Depth ft <br /> COMMENTS <br /> PE SC ReceivedChec Amount Date Permit' <br /> Invoice# Well 10# <br /> Codes It ash Remitted Service Re uest# <br /> O ). 2 i. VV - �.17 <br /> 12 <br /> 'Z I — �2J P. <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />