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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 <br />CROSS STREFT �_4 1{JI V_J:'L <br />OWNER NAME <br />OWNER ADDRESS <br />0 <br />CONTRACTOR <br />CONTRACTOR ADDRESS ao o I n 111 <br />SUBCONTRACTOR <br />rn <br />CITY/ZIP m <br />APN 'v v �/ PARCEL SIZE C1- LAND USE APPLICATION # o <br />a(37--�L 5 / �0 <br />PHONE �CA o d zb� CITY/STATE/ZIP C �� <br />i 7T /f r 11 PHONE /_U / <br />CITY/STA <br />PHONE <br />SUBCONTRACTOR ADDRESS4:19CCITY/STATE/ZIP <br />'VJLJL <br />LICENSE C 57 C-61 i7 D-09_VbW NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i 1 General MineFG�'f ) ❑ Dibromochloropropane (4392) 1 Arsenic (4393) <br />INTENDED USE X Domestic/Private I I Irrigation/Agricultural Industrial i I Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System P 1, <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑Soil Boring#of borings s) I I Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal I I Cross -Connection Repair <br />so 1 borings i� <br />. (�( 2 Z 2/790 <br />❑ New Pump KPump Replacement Fl Pump Repair I 1 Raise Well Casing " vvCA l -1 <br />WELL CONSTRUCTION NEyCTy ONMFNC, <br />UN <br />Drilling Method ❑ Mud Rotary I Air Rotary i Auger I Cable Tool Push Point i Other IDI'A Zi_ <br />Proposed Well Depth ft Excavation in diameter Open Bottom I Gravel Pack/Gravel Size In diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method I Pumped ❑ Free Fall 11 Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By I I Driller ❑ Pump Contractor I Other <br />I I Concrete Pedestal -]Dimensions: Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br />PUMP Submersible I ! Turbine ❑ Other HP Pump Set ft Standing Water Level ftt <br />1 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 />WORKERSAOMPENSATION LAWS. <br />E NOTW <br />,E REQUIRED <br />EPLR <br />MENWT <br />E N L Y <br />Application Accepted By <br />Date <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />- PLEASE CALL (209)975? -7 <br />DATE / (/ i <br />Area t ` Employee ID# 44-("e <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Che Amount Permit/ <br />Cod s Info B as emitted Date Service Request # Invoice # Well ID# <br />We0QZ0gLjq <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />