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WELL/PUMP PERMIT <br />SAN JOAWUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />GALL (ZUy) `J0J-/bV1 FOR INSPECTIONS <br />CITY/ZIP <br />_ APN PARCEL SIZE(-?- <br />t h o 1 w i t i ia <br />.! it <br />A I7A!AJVJ I/)rv� CITY/STATE/ZIP <br />❑ D-09 ❑ Other. <br />NUMBER <br />G/U" imca I T tAK I-KUIVI UA I t IJJUtU <br />- -- - - <br />AND USE APPLICATION # <br />PHONE <br />PHONrz <br />PHONE <br />EXPIRATION DATE-4L-Z-111- <br />17Z <br />ATE <br />DOMESTIC WELLS PLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification F] Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />E] Out -Of -Service II E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />El New Pum W Pum Replacement [-]Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary El Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter El Open Bottom [-]Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP 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 />WORKE OMPENSATION LAWS. <br />I A Ct NOTICE REQUIRED FOR I7PMECTI-PLEASE CALL (209) 995 76n97�%�SIGNED TITLEU� DATE l7j(!/, 4 /7 <br />j� DE ARTMENT U E QNLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By + Date rJ ,- <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />Area Employee ID#� <br />PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received a Amount Date <br />C,oggs Info B Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />cl /6 <br />7 7 �'ba 3? t? <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />