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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 />NUN-KEFUNDABLE PERMIT <br />WWW.Spqv.qE9lettq <br />APIKtS 7 YEAR FROM DATE ISSUED <br />I If 11 <br />JOB ADDRESS <br />CITY/ZIP <br />CROSS STREE,PARCEL <br />SIZE _ <br />LAN6 USE APPLICATION' <br />#� <br />OWNER NAME <br />MW� <br />PHON <br />OWNER ADDRESS <br />CITYISTATE/ZIP <br />CONTRACTOR <br />PHONE ' <br />CONTRACTOR ADDRESS 0 <br />CITYISTATE17JP <br />SUBCONTRACTOR/CONSULTANT44 <br />PHONE <br />1 <br />SUBCONTRRACT/9_R/CONSULTANT ADDRESS <br />LICENSE ' (,,'-57 J C-61 `. D-09 <br />I TATE/ P <br />1. Other NUMBER <br />EXPIRATION DATE <br />BILLING PARTY: J OWNER <br />.I CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: ! General Mineral/Coliform Bacteria (4391) iii Dibromochloropropane (4392) Li Arsenic (4393) <br />NTENDED USE Domestic/Private -: 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 F Other <br />tutoring Well(s) # of wells :! Soil Boring(s) # of borings Geotechnical # of borings <br />Out-Of-Servit 11 Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump I 'umo Replacement !_ Pump Repair I Raise Well Casino <br />Drilling Method _ Mud Rotary , Air Rotary J Auger i Cable Tool ! Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom 7 Gravel Pack/Gravel Size in diameter <br />1. Conductor Casing In diameter / Conductor Casing Depth It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad 7 Steel :: Plastic - Stainless Steel I Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal wafer) Sand Cement sack mixn gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method G Pumped Free Fall ❑ Other ii Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller :_: Pump Contractor _.i Other <br />-i Concrete Pedestal .:Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />r� <br />PUMP 1­4iQ bmersible, Turbine Other HP Pump Set a erg^ - <br />I HEREBY CERTIFY — <br />JOAQUIN COUNTY <br />CURRENT AND ACI <br />WORKERS CO PEN <br />M{ , <br />SIGNED —=; <br />�) P I ),i-' , r.), <br />DEPARTMENT S ONLY <br />Application Accepted By Date S Z'�Area "? � � Employee ID# A J� <br />Grout Inspection By Date iJ SPECIAL Well Permit <br />Pump Inspection By Date J WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS _ __ <br />EHD 4306 6/112019 WELL /PUMP PERMIT <br />r <br />