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WELL/PUMP PERMIT <br />SAN JOAQUIN GOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE - STOCKTON CA 952D$ - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />ADDRESS <br />STREET <br />I:i3Td <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE Yt C-57 D C-61 ❑ D -0g ❑ <br />v J'�,(� 1{µA (� arn�z(l�P 1 i(t^�i �U N i (� �i r'i'�J �' lGl O <br />2�t �i� 1 ID— iJ�O PARCEL SIZE iV •Lt/ LAND U9E�AtPA{P�ALAICAT�ION# ( � <br />PtHO(N�E � �V"/!/� �'Jq� � �✓J/�n <br />J CITY/STATE2IP }�I1�ON �W ���Y/lY <br />CITY/$TATE/7JP,riYr IJVr �7✓`/ / <br />PHONE <br />_ Cm/STATE/LP <br />NUMBER ��� EXPIRATION <br />DOMESTIC WELL SAMPLING: � General Mineral/Coliform Bacteria (4391)�°I Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE <br />l7 <br />❑ IndusVial ❑ <br />Public Water System <br />If dlflerent hom Owner. Water System Name <br />Monitoring ❑Soil Sampling/Characterization <br />Contact Name or Phone Number <br />TYPE OF WORK �� , yew Well � Replacement Well ❑Well AReration/Modification ❑Other <br />0 �vlonitoring Wells) # 01 wefts ❑Soil Borings) # or borings ❑ Geotechnical <br />❑ Out -Of -Service WeII ❑Dut-Of-Service Well Renewal pCross-Connection Rapair <br />N of borings <br />❑ <br />New Pum ❑Pum Re <br />lecement <br />❑Pum Re air <br />❑Raise Well Casin <br />WELL CONSTRUC���TItttON <br />Drilling Method 7� Mud Rotary ❑Air Rotary ❑Auger O <br />Cable Tool ❑Push Point ❑ Other <br />+` r <br />Proposed Wall Depth R Excavation _l�� <br />fn diameter <br />❑Open Bottom D Gravel PacWGravel Size in diameter <br />❑ Conductor Casing in diameter / <br />Conductor Casing <br />Depth R <br />ane❑ <br />ter<pp <br />WGrorit <br />Steel j,( tainless Steel ❑ Othsack <br />Steal Depih ft Neat CementA(94c16 <br />bag15�ate� <br />,l�Sand Cemerrt mix/7 gal water <br />�Bentonile (20 %solids) ❑Other <br />Grout Placemen ethod Pumped ❑Free Fall D Other <br />❑Retardant /Accelerator (name) <br />PEDESTAL Installed By ❑Driller ❑Pump Contractor <br />❑ Other <br />D Concrete Pedestal ❑D(menslona: Width <br />R Lengih <br />R Thick in D Christy Box ❑Stove Pipe <br />PUMP ❑Submersible❑ Turbine ❑Other <br />HP <br />Pump Set ft Standing Water Level R <br />1 HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REOUIRED 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 />DEPARTMENT USE ONLY <br />Application Accepted By � � Dete J' � Q Area / � �� Employee ID# .1✓� <br />Grout Inspection By _�. r1L .�. � t r Date � ❑ SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring <br />pate <br />❑ WAIVER Received <br />Constructed Well Depth <br />EHD 43-09 8101/1G <br />WELL 1PUMP PERMR <br />T <br />m <br />v <br />A <br />w <br />:: <br />T® <br />1►�i� %�I�es�*JE <br />rnb�r��►�� <br />�a����■�� <br />���� <br />EHD 43-09 8101/1G <br />WELL 1PUMP PERMR <br />T <br />m <br />v <br />A <br />w <br />