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bO <br />WELL/PUMP PERMIT <br />D <br />n Y) SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468.3420 <br />V O�ZNON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />O 7 Jo O ss Cm/``L^^P <br />CROSS STREET APN PARCEL SIZE yy6 �LAND USEAPPLICATION# <br />n <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CITY/STATE2IP <br />PHONE <br />PHONE ' /cL`j — <br />CONTRACTOR ADDRESS <br />T <br />\ CITY/STATE2IP C <br />L, i\�t �-. w I/P d l f Y.. <br />�- <br />SUBCONTRACTOR/CONSULTANT ' <br />1I� <br />1 ` <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />r t <br />' �7 <br />CIN/STATE2IP, <br />it- <br />LICENSE 17L:-57 D C-61 ❑ D-09 <br />D Other <br />�-- <br />NUMBEI �- <br />EXPIRATION r­.iT <br />BILLING PARTY: D OWNER <br />D CONTRACTOR <br />D SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring Wfooil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well D Replacement Well D Well Alteration/Modification D Other <br />D Monitoring Well(s) # of wells D Soil Boring(s) s of borings Geotechnical u of borings <br />D Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair I <br />D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method @'Mud Rotary C Air Rotary /Auger ❑ Cable Tool /Push Point C Other <br />Proposed WeII Depth �i n ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter I TrIckness/Gauge/ASTM Sched 7 Steel 7 Plastic 0 Stainless Steel D Other <br />Grout Seal Depth Meat Cement (94 Ib bag/5-10 gal water) � Sand Cement sack mix/7 gal water <br />❑ Bentonl 20 % solids) C Other <br />Grout Placement Method pumped C Free Fall D Olher C Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller D Pump Contractor 7 Other <br />Li Concrete Pedestal LiDimensions: Width ft Length ft Thick in L Christy Box L Stove Pipe <br />PUMP I I Submersible I Turbine I 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 48,"$OUR.,ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED r"'-�� TITLE 'Tq (G,�r� CE..M DATE <br />Application Accepted By <br />Grout Inspection BS <br />Pump Inspection By <br />Soil Boring Inspection By <br />MMgNT <br />�. v IRVfVl1q <br />ZENT U NLY TALHEALTH <br />ate ` 'j PER VIQFq�Syee ID# <br />Date D ❑ SPECIAL Well Permit <br />Date ❑ WAIVER Received <br />Amount <br />Date <br />Service <br />y <br />m <br />n <br />0 <br />m <br />ti <br />Constructed Well Depth ft <br />L <br />_.y <br />Invoice III Well ID# <br />EHD 43-0fi 6111r1019 �161 D2.7yL r V/ V UMPPERMIT <br />