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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.S' OV.OT /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />Dnlling Method Mud Rotary _ Air Rotary _ Auger ._ Cable Tool _Push Point <br />Proposed Well Dh <br />e lhOther <br />Conductor Casing <br />P Excavation in diameter - Open Bottom -. Gravel Pack/Gravel Size <br />in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br />Grout Seal De UI : Steel _Plastic Stainless Steel -Other <br />P ft - Neat Cement (94 /b bag/5-10ga1 water) Sand Cement <br />Bentonite (20% solids) _ Other Sack mix/7 gal water <br />Grout Placement Method - Pumped Free Fall Other <br />Retardant/Accelerator (name) <br />PEDESTAL Installed By Onller = Pump Contractor Other <br />Concrete Pedestal _ Dimensions: Width ft Length R Thick <br />in - Christy Box - Stove Pipe <br />uMP Submersible Turbine - Other HP Pum Set P ft Standing Water Level it <br />I HEREBY CER IFY 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 LA <br />JQiU NCE %NOTICE REQUIRED F01INSPEC,fTI�ONS - PLEASE CALL (209) X53�-7g <br />SIGNED Tin '- G%'/y <br />�+�---� UtrARTMENT USE ONLY <br />Application Accepted By DaleArea �/ CSC! <br />Employee,D# <br />Grout Inspection By Date <br />SPECIAL Well Permit <br />Pump Inspection By 2"' Date L - <br />WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS Date Constructed Well Depth ft <br />PAYMENT <br />RECEIVED <br />AUG 0 3 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />VrLL PUMP PERMIT <br />CITYZP-JC,!L•! <br />CROSS STREE <br />Q L <br />APN� (� �'� )� r=PARCEL SIZE (r LAND USE APPLICATION <br />OWNER NAME <br /># <br />r.� <br />OWNER ADDRESS �J <br />�(�%j+` <br />PHONE Cil/( /V <br />CITYISTATEZP-J;-,�,�.tL-L_/ <br />CONTRACTOR 6-I—t <br />! � <br />CONTRACTOR ADDRESS <br />PHONE <br />CITY/STATEZP <br />SUBCONTRACTOR/CONSULTANT <br />1Z <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />4zo, PHONE <br />v <br />LICENSE A C-57 C-61 D-09 <br />TYlSTATEZp Yv <br />(V <br />BILLING PARTY: <br />J Other / <br />NUMBER E%PIRATION DATE <br />_: OWNER <br />_ CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />OOMESTIC WELL SAMPLING: _. General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) _ Arsenic <br />(4393) <br />INTENDED USE DOmestlC/Privale _ Irrigation/Agricultural 'Industrial Water Ouali Monilorin <br />h <br />Public Water System <br />9 Soil Sampling/Characterization <br />If different from Owner <br />Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MOnitoring Well(s) <br />Out -Of -Service Well <br /># of wells Soil BOring(s) # of bonngs <br />Geotechnical # of borings <br />Out -Of -Service Well Renewal = Cross -Connection Repair <br />New Pump Replacement - Pump Repair <br />WELL CONSTRICTION <br />Raise Well Casino <br />Dnlling Method Mud Rotary _ Air Rotary _ Auger ._ Cable Tool _Push Point <br />Proposed Well Dh <br />e lhOther <br />Conductor Casing <br />P Excavation in diameter - Open Bottom -. Gravel Pack/Gravel Size <br />in diameter / Conductor Casing Depth ft in diameter <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched <br />Grout Seal De UI : Steel _Plastic Stainless Steel -Other <br />P ft - Neat Cement (94 /b bag/5-10ga1 water) Sand Cement <br />Bentonite (20% solids) _ Other Sack mix/7 gal water <br />Grout Placement Method - Pumped Free Fall Other <br />Retardant/Accelerator (name) <br />PEDESTAL Installed By Onller = Pump Contractor Other <br />Concrete Pedestal _ Dimensions: Width ft Length R Thick <br />in - Christy Box - Stove Pipe <br />uMP Submersible Turbine - Other HP Pum Set P ft Standing Water Level it <br />I HEREBY CER IFY 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 LA <br />JQiU NCE %NOTICE REQUIRED F01INSPEC,fTI�ONS - PLEASE CALL (209) X53�-7g <br />SIGNED Tin '- G%'/y <br />�+�---� UtrARTMENT USE ONLY <br />Application Accepted By DaleArea �/ CSC! <br />Employee,D# <br />Grout Inspection By Date <br />SPECIAL Well Permit <br />Pump Inspection By 2"' Date L - <br />WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS Date Constructed Well Depth ft <br />PAYMENT <br />RECEIVED <br />AUG 0 3 2021 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />VrLL PUMP PERMIT <br />