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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 <br />"3.17697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITY/ZIP <br />CROSS STREETA" MAIQIKPAPN <br />' PARCEL SIZE <br />LAND USE APPLICATION # <br />OWNER NAME <br />PHONECP0qr D — 591 S_ <br />I <br />OWNER ADDRESS13 01 D <br />CITY/STATE/ZIP Lod <br />CONTRACTOR <br />-PHONE <br />%� � <br />-01 /fal'D <br />CONTRACTOR ADDRESS22,-D�/ /T(-� Y� _( lQ <br />CITY/STATE/ZIPU <br />j <br />SUBCONTRACTOR 404 <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CIJY,/STATE/ZIP <br />LICENSE \tl, C-57 ❑ C-61 ❑ D-09 CI Other <br />NUMBER <br />EXPIRATION DATE / ✓/ <br />)OMESTIC WELL SAMPLING: General Mineral/COIItorm Bacteria (4391) UlbroMOChloropropane (4392) Arsenic (4393) <br />NTENDED USE y <br />Domestic/Private ❑ Irrigation/Agricultural Ll Industrial a Water Quality Monitoring u 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 ❑ Other <br />11Monitoring Well(s) # of wells [I Soil Boring # of boringss) CI Geotechnical q,t <br />❑ Out -Of -Service II ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump K Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION *: .1 <br />Drilling Method 11Mud Rotary ❑ Air Rotary LlAuger [jCable Tool I i Push Point ❑ Other S 2018 <br />Proposed Well Depth ft Excavation in diameter ( I Open Bottom ❑ Gravel Pack/GravEe:1AQU/;dbkiameter <br />11 <br />in diameter / <br />th <br />At <br />Well Casing Diameter ctor Caning Thickness/Gauge/ASTM Sched Conductor Casing Delp Steel F] Plastic ftStainless Steel❑LOth`e�lVpgR hfely <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 I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller CI Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine ❑ Other HP A Pump Set ft Standing Water Level ft <br />I HEREBY CERTI) Y 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 />SIGNED <br />Application Accepted By(�(/^Cly`�L�y�``� Date v_ r L / y <br />Grout Inspection By Date <br />Pump Inspection By N �1�� �,��� �k 14Y� Date k 6 l g I l b <br />Soil Boring Inspection By Date <br />COMMENTS <br />rService <br />!VAGI=29Mrfj l![�i J[�.. ► , <br />Area Employee ID# <br />Ll SPECIAL Well Permit <br />Cl WAIVER Received <br />Constructed Well Depth <br />ft <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />IrL <br />