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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />nvn-IKtFUNlJAIJLE rERMIT . L;ALL (1U9) 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS L V p ? CITY/ZIP ��Tv`- K' 1 V 1 V�1-I <br />1-2 <br />CROSS STREET � APN O D 71 � 0 1 J PARCEL SIZE �' LAND USE APPLICATION # <br />OWNER NAME CA" PHONE <br />OWNER ADDRESS � � V V )1 � ° CITY/STATE/ZIP V\ I/y�`L 67c> � <br />CONTRACTOR "I 1,124) <br />/ ns �Q +CllIS PHONE(j'r - Iy� j 0 <br />CONTRACTOR ADDRESS ` 1 � \) y �/ �C PJ11 CITY/STATE/ZIP C4a, J <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE /C-57 X-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP— <br />NUMBER u, <br />PHONE <br />EXPIRATION DA <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial E] Water Quality Monitoring El 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 />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pum j(Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool 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 Ib bag/5-10 gal water) []Sand Cement sack mix17 gal water <br />❑ Benton ite (20% solids) [-]Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP VSubmersible ❑Turbine. ❑Other HP t L- 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 LICENCE 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 />EPARTMENT USE ONLY <br />Application Accepted By Date—C/-/-/7- <br />ate C/ - / r / / <br />Grout Inspection By Date <br />Pump Inspection By Date b <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area C/ Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />rr <br />M <br />D <br />0 <br />v <br />m <br />m <br />rn <br />U) <br />PE <br />Codes <br />SC Received hecW <br />Info B <br />Amount <br />Remitted <br />to Permit/ Invoice # Well ID# <br />Service Request # <br />3i <br />o5� <br />2-4 1 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />