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WELL/PUMP PERMIT <br />AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209( 468-3420 <br />NON-REFUNDABLE J�PERMIT <br />Joe ADDRESS may] <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS],L <br />n <br />APN <br />CONTRACTOR ADDRESS 11-1 11 11/ y I I I m <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE yC-57 0 C-61 ❑ D-09 ❑ Other <br />953-7697 FOR INSPECTIONS EXPIRE5 1 YEAR FROM <br />C""P malOR14FIS <br />ffp�PARCEL LAND USE APPLICATION #_ <br />PHHONE -541 - <br />r. rcr..en e l n I D N 1 q <br />CITYISTATEMP. <br />PHONE <br />CRYI(S'yTATERIP <br />]1__ X—Q <br />NUMBER — 1 EXPIRATION <br />2 <br />DOMESTIC WEu-SAMPLING: General Mineral/Coliform Bacteria (4391) ADibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE DomestidPrivate U Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />.] Public Water System <br />If dieerent from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK [I New Well Replacement Well ❑ Well AlterationlModification ❑ Other <br />❑ Monitoring Wells) # of wells E] Soil Boring(s) <br />s of boring' C Geotechnical a'1 bo v ps <br />❑ Out -Of -Service Well 7 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump 0 Pump Replacement ❑ Pump Repair ❑ Raise Well Casio <br />WELL CONsrauc�no/N <br />Drilling Method pl Mud Rota U Air Rotary ❑ Auger G Cable Tool o Push Point ❑ Other <br />!D� <br />Proposed Well epth ft Excavation t• �'in diameter ❑Open Bottom ❑Gravel Pack/Gravel Siz n diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well CasingDiameter ur-�7777h(yppcl��c{��ess/Gau a/ASTM Sched no ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth [ U 0 Neat Cement (94 It, bag15-10 gal water) D Sand Cement sack mixA gal water <br />R Sento 'te (20% solids) ❑ Other <br />Grout Placement Mothod Pumped U Free Fall ❑ Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor 0 Other <br />❑ Concrete Pedestal ODlmonsions: Width ft Length ft Thick in ❑ Christy Box L'r Stove Pipe <br />PUMP U 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 COMPENSATION LAWS. <br />Y 1 F/V . <br />AFD <br />2 2021 <br />4MCo"Ty <br />P,q N T,4 L <br />TMeNT <br />DEPARTMENT USE ONLY <br />Application Accepted By L_ Date 7 -�/� Area / A Employee ID# i <br />Grout Inspection By Date ❑ SPECIAL WBII Permit <br />Pump Inspection By Dale ❑ WAIVER Received <br />Soil Boring Inspection By Date Constr iedLWrll Depth 4� ft <br />COMMEj�fTS " r <'�tri - t'Yl tiNr. �e 1I l . ,t!a 1 1. ��( Y /..ii! /`! r! e- Pvl j <br />[•,ac,/, r,�.: F [o:vtrlr::f, ,tn,:,,:1.. � S: �� P Cr%��lt rr��L.- rui�liS'- <br />MM EMEMER-T. Mm <br />''�1�1!/�':SrI�ElEi�7� <br />� <br />��L��ry%JiiiT/�E1S►1�7® <br />� <br />EHO43-06 8101118 coq- WELL/PUMP PERMIT <br />