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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 />NON-REFUNDABLE PERMIT CAL4 (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS / CITY/ZIP L-4J=M1 / L F/ T —I' Jp(`r CK <br />CROSS STREET PN O S J� U b 0'U PARCEL SIZE LAND USE AA�PPP�LICCATION # <br />OWNER NAME R_l� L� � t4 � PHONE /�V 1' 3 I �� q <br />OWNER ADDRESS S 3� U v 1 ('t_ 15 1" C Dr CITY/STATE/ZIP 7�0 I V� <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE V13-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />PHONE <br />C /STA <br />TE/ZIP <br />NUMBER " r EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />INTENDED USEomestic/Private ❑I Irrigation/Agricultural 11Industrial 11Water Quality Monitoring 11Soil 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 />❑ Monitoring Well(s) *of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service VII [1 Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I New PumD 1Y umo Replacement ❑ PumD Reoair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1-1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter LI 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 f I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal wate/) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 1.1 Other !I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible❑ Turbine I 1 Other HP 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 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 />(!�,Knpon <br />hMUM24 HDVANCE NOT E REQUIRED FOJR�NSAPECTI�1� PLEASE CALL (209) 953-76971 <br />SIGNED J i 0 A 1� TITLE �� �v:ta� DATE <br />DE ARTMENT USE ONLY <br />Application Accepted By Date �G l <br />Grout Inspection By Date y <br />Pump Inspection By Date ®t v 312-c <br />0 <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area 4G Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />PE SC Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />