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a 'y <br />` WELL/PUMP PERMIT f <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL <br />JOB ADDRESS <br />CROSS STREET [OiAPN <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR Un11 JVIV44 NZ 14otA- <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACT& ADDRESS <br />LICENSE NC -57 ❑ C-61 ❑ D-09 ❑ Other <br />953-7897 FOR INSPECTIONS <br />— ZIC /! / <br />IKtb 'I YEAR FROM DATE ISSUED <br />CITY/ZIP �-) I LA -4-4 [.y I OF 1- r �/ <br />PARCEL SIZE •LAND USE A/I <br />PPPLCAlTTIION # <br />�/7/7Q <br />PHONE G.(/" —y :31— <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP C14/. Q (__�C.( <br />PHON <br />CITY/STATE/ZIP <br />NUMBER <br />EXPIRATION DATE <br />DOMESTIC WELL PTPILING: ❑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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) E] Geotechnical # of borings <br />❑Out -Of -Service ell E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />F] New Pump X61 Pump Replacement Fl Pump Repair F] Raise Well Casinq <br />Drilling Method []Mud Rotary E] Air Rotary []Auger [:]CableTool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] 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 />F-1 Concrete Pedestal Dimensions: Width ft Length ft Thick in [-]ChristyBox ❑Stove Pipe <br />PUMPASubmersible ❑Turbine ❑Other HP___I_ Pump Set 1"IV 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 />WORKERS COMPENSATION LAWS. <br />E <br />DE ARTMENT USE ONLY <br />Application Accepted By _ Date l <br />Grout Inspection By 7 Date <br />Pump Inspection By I Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />ZI <br />1 <br />m <br />D <br />0 <br />v <br />m <br />m <br />w <br />ur <br />Area1515/j?lEr„p:oyee <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info By Cash Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />