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v' .t <br />WELL/PUMP PERMIT <br />SAN `'i AOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CITY/ZIP i <br />C? 452)C5 m <br />CROSS STREET <br />n <br />APN ©� L— PARCEL SIZE t <br />D <br />LAND USE APPLICATION # <br />TAOWNER <br />I <br />WWWcn <br />NAME <br />e- ) <br />PHONE <br />OWNER ADDRESSC41 <br />ITY/STATE/ZIP <br />HMMM <br />CONTRACTOR <br />P ONE <br />CONTRACTOR ADDRESS <br />1 CITY/STATE/ZIP�� <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />- <br />LICENSEC-57 61 <br />❑ D-09 ❑Other NUMBER <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE%150mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑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 E] Replacement Well ❑Well Alteration/Modification E] Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />E] Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pum Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] Air Rotary []Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter F] 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 E] Stainless Steel E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb 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 E] Pump Contractor ❑ Other <br />F-1 Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP submersible❑Turbine ❑Other HIP IPump 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 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 />MI OUR ADVANCE NOTICE REQUIRED FO INSPECT ONS - PLEASE CALL (209) 9-76p.7 <br />, ^76 7 <br />SIGNED TITLE L DATE q t <br />App%cation Accepted Sy <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE <br />ate <br />ONLY <br />Date <br />Date <br />I <br />Date <br />Area Employee ID# <br />❑ <br />SPECIA1 Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Cash Remitted Service Request # <br />372. <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />