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WELL/PUMP PERMIT <br />SAN JOAQUIh CCkJNTY'AENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT V1j„ CALL (209) 95 697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS r Z CITY/ZIPmcm 73 <br />CRUSS STREET ' / / PN 075 r� (J L PARCEL SIZE 'A LAND USE <br />7AA�PPLICATION # _ <br />O'lER NAME J C HONED <br />OWNER ADDRESS 3 ✓ L OfI Y/STATE/ZIP 1 �` y — `� • �I <br />CONTRACTOR ^ PHONE <br />CONTRACTOR ADDRESS ki I CIN/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACT ADDRESS <br />ClTATE/ZZIPP ) <br />LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER :'3 ( t[/ EXPIRATION DATE / J <br />DOMESTIC WEL �gMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE !Domestic/Private ❑Irrigation/Agricultural ❑Industrial [-]Water Quality Monitoring ❑Soil Sampling/Characterization <br />ublic Water System <br />If different from Owner Water System Name Contact ame one um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification El Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ G c k <br />❑ Out-Of-Service,W I <br />L] Out -Of -Service Well Renewal ❑Cross -Connection <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger []CableTool F-1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />w <br />t i -sing in diameter / Conductor Casing Depth ft <br />Well In Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑Other <br />Grout Sea ft [:1 Neat Cement (94 Ib bag/5-10 gal water) E] Sand Cement sack rnix/7 gal water <br />n solids) ❑Other <br />Grout P16cment Method ❑Pumped ❑Free Fall E] Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By []Driller El Pump Contractor ❑ Other I <br />El Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />rE It 11 <br />PUMP Jt Submersible ❑Turbine ❑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 />E <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS ►.irt CC f7 <br />Date I(, `f <br />Date <br />Date <br />Date <br />Area ki '� I 'A''\ Employee ID# ley <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructe Well Depth ft <br />r,& to (' r-3 C e,1I . 7 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />hec <br />Cash <br />Amount <br />Remitted <br />Date <br />Permit/ Invoice # Well ID# <br />Service Request # <br />77 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />