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WELL/PUMP PERMIT P <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE VERMIIT ,✓^ L UALL ZU`J yb3-/bU1 FOR INSPECTIONS CCJIt'Ih(CJ "I TEAR FROM UAIE 155UEU <br />LE6- <br />JOB ADDRESS / y / 5 I���C A / CITY/ZIP `, 4 L; c �� n <br />CROSS STREET C�/�,/� L��� J/�/ �A�P /N 17 f Q( U l PARCEL SIZE y' 7 ) LAND USE APPLICATION #_ <br />OWNER NAME o!/ � G/\/��S��s�JC L iG N1 F-H0NE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR I/%l /� Ly/` /�,/A//!� / r �///�!��"L c��/ PHONE <br />„/ <br />CONTRACTOR ADDRESS 2f ZL� /�[� !�L_ti� / ALJ CITY/STATE/ZIP <br />SUBCONTRACTOR �� PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE �)(C-57 �oXC-61 I D-09 J Other <br />CITY/STAT E/ZI P <br />NUMBER L L; Y (. EXPIRATION DATE , S <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) I I Dibromochloropropane (4392) CI Arsenic (4393) <br />INTENDED USEDomestic/Private I_ Irrigation/Agricultural LI Industrial Ll Water Quality Monitoring Li Soil Sampling/Characterization <br />Li Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />a <br />ash <br />Amount Date <br />Remitted <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I Geotechnical A f borings <br />S S S <br />[I Out -Of -Service Well [I Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />���`1IYiwe'v`r” <br />�� <br />F1 New Pum um Replacement F1 Pum Repair I1 Raise Well Casing <br />WELL CONSTRUCTION <br />pp�� <br />JAN 0 <br />Drilling Method <br />U Mud Rotary I_l Air Rotary I Auger I I Cable Tool [I Push Point ❑ Other <br />3 20". <br />Proposed Well <br />Depth ft Excavation in diameter ❑ Open Bottom I I Gravel Pack/Gravel <br />In diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />8 ENVIROIVM <br />L <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched [I Steel Ll Plastic i I Stainless Steel <br />11 i��li�pEP <br />Grout Seal <br />Depth ft l Neat Cement (94 Ib bay15-10 gal water) ❑ Sand Cement <br />sack mix/7 gal water <br />❑ Bentonite (20% solids) I Other <br />Grout Placement Method I -I Pumped ❑ Free Fall 1 Other [ I Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By 11 Driller ❑ Pump Contractor I I Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in I Christy Box i i Stove Pipe <br />PUMP JVS'ubmersibleI1 Turbine I I Other HP _ Pump Set / r0l ft Standing Water Level /I6LI I 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 />SIGNED <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE <br />DATE <br />Application Accepted By Date 5 Area �� Employee ID#� <br />Grout Inspection By Date k I Fl SPECIAL Well Permit <br />Pump Inspection By Date f I WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />M <br />M <br />D <br />0 <br />0 <br />M <br />U) <br />U) <br />PE <br />Codes <br />Sc Received <br />Info B <br />a <br />ash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />S S S <br />D S L'• <br />�� <br />2sb -7 7 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />