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13 <br />` 3 -7 �LI a WELUPUMP PERMIT <br />SAN JOAQUIN LINTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AvENUE - STOCKTON CA 95205 - (209) 488-3420 <br />NON-REFUN ABLE PERRmrr _ j I CALL 209 953-7697 FOR INSPECTIONS <br />�EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS %/ZVrl/���./V� �r� <br />CROSS STREET VIN) <br />j <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS _ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />APN Zj1_11,0_3140 PARCEL SIZE LAND USE APPLICATION # <br />0 C-61 ❑ D-09 0 Other. <br />PHONE <br />1 ` U r) 0 ijQ-� <br />� Q 11 1 <br />CrrY/STATE/ZIP BOO j, • Grp �r`'/ �J �+ `/a <br />PHONE �V- l ✓�v I "1�� <br />CITY/STATEMP <br />PHONE <br />CITY/STATEMP <br />NUMBER � ZZ F_7CPIRATION DATE <br />DOMESTIC WELL SAMPUNG: ❑ General Mineral/Coliform Bacteria (4391) O Dibromochloropropane (4392)17 Arsenic (4393) <br />INTENDED UaE 0 Domestic/Private Irrigation/Agricultural 0 Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />0 Public Water System <br />If dKerenf from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK A New Well ❑ Replacement Well 0 Well AReration/Modification <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) <br />0 Out -Of -Service Well 0 Out -Of -Service Well Renews <br />❑ Other <br />s <br />of borings 0 Geotechnical <br />1 0 Cross -Connection Repair <br />A d bwkVs <br />WELL Drilling Method Mud Rota ❑Air Rotary ❑Auger 0 Cable Tool ❑Push Point 0 Other <br />Is <br />Proposed Well Depth it Excavation V in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / CondLIctor Casing De th It <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad I II Steel 0 Plastic ❑ Stainless Steel 0 Other <br />Grout Seal Depth it ❑ Neat Cement (94 lb bagi5-10 gal water) Sand Cement U •'J sack mixl7 gal water <br />❑ Bent ite 20% solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller ❑ Pump Contractor ❑ Other <br />0 Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box 0 Stove Pipe <br />p ❑ Submersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level it <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 />WORKERS COMPENSATION LAWS. <br />i <br />Application Accepted ByG- L <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />DEPARTMENT USE ONLY <br />Date 10 d,0 cY <br />Date <br />Date <br />Date <br />Area CEmployeelD# <br />❑ SPECIAL Well Pertrtit <br />❑ WAIVER Received <br />97", TITWE <br />EHD 43-06 801/18 <br />1333��S3S <br />WELL /PUMP PERMfr <br />EHD 43-06 801/18 <br />1333��S3S <br />WELL /PUMP PERMfr <br />