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SAN JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMWELL/PUMP PERMIT <br />1868 EAST HA2ELTON AVENUE -STocK7oN CA 95205 6232 (209)468-3420 <br />NON-REFUNDABLE PERMIT WWW. OV.OI' /ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />[CROSS <br />RESS , <br />CITY/ZIP <br />TREET APNO 13 fp�yJJJ��1PARCEL SIZE BLAND USE APPLICATIONNAMEPHON�ADDRESS f',1'^CITYI$TATEIZIPCTOR G'__•�PHONE%CC�JL!TOR ADDRESS - N , CITY/STATE/ZIP RACTOR/CONSULTANT <br />PHONE <br />RACTOR/CONSULTANT ADDRESS <br />\/ C STATE/ZIP -1 <br />LICENSE X, C-57 C-61 0-09 1 Other NUMBER ER EXPIRATION DATE J <br />BILLING PARTY: OWNER _' CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DoMEsnc WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE DomestiGPrivate Irrigation/Agricultural - Industrial - Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name <br />Contac( Name or Phone Number <br />TYPE OF WORK - New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bonng(s) # of bonngs Geotechnical of borings <br />Out -Of -Baru ce ell Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Replacement Pum Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger _ Cable Tool Push Paint Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom i. Gravel Pack/Gravel Size <br />Conductor C. n diameter <br />Casing_ in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad <br />Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other sack mix/7 gal water <br />Grout Placement Method - Pumped Free Fall Other _ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller _- Pump Contractor - Other <br />Concrete Pedestal ;Dimensions: Width ftLength ft Thick <br />� { in Christy Box Stove Pipe <br />L. --r X Submersible _ Turbine - Other HP <br />I HEREBY CERTIFY THAT I HAPum Sel <br />P ft Standing Water Level ft <br />VE 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 />I �uEPARTMENT USE ONLY <br />Application Accepted B '�/,`/ <br />P y Date S l� Area / Employee ID# <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date I �. WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth <br />COMMENTS ft <br />WELL /PUMP PERMrr <br />