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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓' (x� CITY21P �� �q0, m <br /> CROSS STREET AP O( Q31(J OO PARCEL SIZE d'0 7 LAND USE APPLICATION# A <br /> m <br /> PW 16 <br /> OWNER NAME PHONE u! <br /> OWNER ADDRESS HalichnL ry� CITYISTATEMPLod 1 r 9sayo <br /> CONTRACTOR /^ PHONE 2D� /y <br /> �/�l1�3)-q,321 D <br /> CONTRACTOR ADDRESS 2IZD 141\cox Tzd CITY/STATEMP� �n� C4 /SF 45 <br /> SUBCONTRACTOR/CONSULTANT / I APHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE *-57 ❑C-61 Cl D-09 ❑Other NUMBER Qn1tv EXPIRATION DATE D <br /> 21 <br /> BILLING PARTY: ❑OWNER Cl CONTRACTOR , SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) It Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE ;'Domestic/Private D Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑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 ❑Soil Boring(s) #ofborings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair �4-fejlvr <br /> ❑New Pum Pum Re lacement ❑Pum Re air ❑Raise Well Casin pA <br /> RWELL CONSTRUCTION e - ;V <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑ Push Point ❑ Other V e6 <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter EP <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft v[l 4 �0?0 <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic D Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water H� DEp N COI J"� <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑ Free Fall ❑Other ❑Retardant/Accelerator(name) �T <br /> MENT <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width it Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP X Submersible❑Turbine ❑Other HP= Pump Set 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM NSA IONIWS. <br /> MINI I OR A -NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL(209)953 697 <br /> SIGNED TITLE DATE <br /> fr <br /> t <br /> LOA <br /> DEPARTMENT USE NLY f1� <br /> Application Accepted ByDate 9/oZ y Area Employee ID# r" <br /> Grout Inspection By q Date ❑ SPECIAL Well Permit <br /> Pump Inspection By FY-'- foA 1:> 0 Lo liwl 2 Date vV'Z V ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PESC Received I'Check#W Amount ate Permit/ Invoice# Well ID# <br /> Codes Info Remitted Service Re nest# <br /> O5O 7 2 <br /> EHD4306 6111(019 - WELLIPUMPPERMIT <br />