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. -& WELL/PUMP PERMIT SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED t ` CITY/ZIP �C—C' L� JOB ADDRESS CROSS STREET e l Y APN 0 I _ p o 1 6 ?1 PARCEL SIZE LAND USE APPLICATION # OWNER NAME -z- /"?, I\ U PHONE ' OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR Ca- l PHONE CONTRACTOR ADDRESS L CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 C-61 El D-09 El Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) NTENDED USE `tail Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization j❑'Public Water System If different from Owner: Water System Name Uontact Name or Phone Number TYPE OF WORK ❑New Well E] Replacement Well E] Well Alteration/Modification E] Other El Monitoring Well(s) # of wells [:]Soil of borings Soil Boring(s) ❑Geotechnical # of borings E] Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair F1 New Pump Pump Replacement [-]Pump Repair ❑ Raise Well Casing Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter E] Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic El Stainless Steel ❑Other Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal wafer) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor X Other ❑Concrete Pedestal dimensions: Width ft Length hick in []ChristyBox ❑Stove Pipe PUMP Submersible❑Turbine ❑Other HP Z Pump Set ft Standing Water Level C. ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORN CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH, ALL WORKERS CPEN ION LAWS. INI'M U 4 HOUE NOTICE REQUIRED FOR INSt, ECTIONS -PLEASE CALL (209) 953 697 SIGNED TITLE r DATE 4 EP RTMENT USE ONLY Application Accepted By Date Grout Inspection By _ _ _ _ De-te Pump Inspection By 1 Date Soil Boring Inspection By Date COMMENTS Area-4Employee ID# I-1 SPECIAL Well Pgrmit WAIVER Received Constructed Well Depth ft PE SC Received Check#/ Amount Date Codes Info By Cash Remitted Permit/ Invoice # Well ID# Service Request # EHD 43-06 8/01116 WELL /PUMP PERMIT