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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 /> JOB ADDRESS CITY/ZIP m <br /> D <br /> 0 <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> ur <br /> OWNER NAME PHONE N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 [i Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1_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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells Li Soil Boring(s) #of borings I 1 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I Push Point [J Other <br /> Proposed Well Depth ft Excavation in diameter LI Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 11 Steel ❑ Plastic I I Stainless Steel ❑ Other <br /> Grout Seal Depth ft I I Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) [I Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall I 1 Other [I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller i_i Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal f]Dimensions:Width ft Length ft Thick in J Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine 11 Other HP Pump Set ft 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> EX <br /> 3AIIJOACIUICDUhT4 <br /> ,MnT <br /> 71 RMAr 111 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By Date Li WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />