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WELL/PUMP PERMIT <br />SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.s ov.OE /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ,� - 1 Q.C) �� hC�n,,n., %1 r10 r` .,i, <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR VAI <br />CONTRACTOR ADDRESS <br />i CITY/ZIP c <br />r -I e -.—'X <br />PARCEL SIZE I LAND USE <br />CITY/STA <br />CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br />PHONE _ <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />�TE/ LICENSEA <br />C-57 C -G1 D-09 OtherNUMBEREXPIRATION DATE <br />BILLING OWNER _ CONTRACTOR _ SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) . Dibromochloropropane (4392) _ Arsenic (4393) <br />���a������ ynwnurai Industnal - Water QualityMonitoring Public Water System 9 Sod Sampling/Characterization <br />If different from Owner: Water System Name <br />Contact Name or Phone Number <br />rvew vveu Replacement Well Well Alteration/Modification Other <br />Monitoring Wells) # of wells ❑ Soil Born s x of borings <br />Out -Of -Service II UO _ GeoteGinical 4 of borings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />_ New Pump Pump Replacement — Pump Repair <br />WELL CfINCTG -Raise Well Casinn <br />Drilling Method Mud Rotary _ Air Rotary _ Auger _ Cable Tool IPush Point <br />Proposed Well De th ft EOther <br />P Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Cast in diameter <br />9 in diameter / Conductor Casing Depth R <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br />Grout Seal De th Steel Plastic -Stainless Steel Other <br />p ft Neat Cement (941b bag/5-10 gat water) Sand Cement <br />Bentonite (20% solids) Other sack mix/7 gal water <br />Grout Placement Method Pumped - Free Fall Other <br />- Retardant /Accleralo, (name) <br />PEDESTAL Installed By Driller - Pump Contractor -- Other <br />- Concrete Pedestal _Dimensions: Width ft Length ft Thick <br />in _Christy Box ._ Stove Pipe <br />PUMP Submersible _ Turbine - Other Hp <br />Pump Set ft Standing Water Level ft <br />I HEREBY CER FY 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 />F.ili'-' 'r//,//qct/�L ^ UR &E NONOTIICE REQUIRED FOR <br />/Iyt,tPPPE�CTIIONS - PLEASE CALL (209) 953-7 9r <br />SIGNED_ !�s —� — -C TITLE `J._/--�. r - <br />W <br />N <br />N <br />.,�rhrc i mcly t U b L ONLY < k J� <br />Application Accepted By Date Area ✓/ ` R <br />Employee ID# / <br />Grout Inspection By Date yyy SPECIAL Well Permit <br />Pump Inspection By Date <br />WAIVER Received <br />COMMENTS Soil Nor ng Inspection By Date Constructed Well Depth ft <br />PE SC Received heck Amount <br />Codes Info Bas Date Permit/ <br />Remitted ervice Request-, n Invoice # I Well ID# <br />4D a3-�� o/t12019 <br />WELL IPUt.'P PERt.IIT <br />