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WELL/PUMP PERMIT <br />SAN 6'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CAL(_ (209) 953-7697 FOR INSPECTIONS _ PXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME S t Ut G C V l c Y\ <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />&U I LVI W—J CITY/ZIP _- to "P rj r —[:=t <br />_ APN 0 G '406051 PARCEL SIZE -�' (/ ZLAND USE APPLICATION # <br />r- u 9 L eMONE <br />( ��� I/l ��//CIITY/STATE/ZIP r r <br />lb -27 <br />117"CITY/STATE/ZIP�T�LGL1214 4 ✓ Cid <br />PHONE <br />CITY/STATE/ZIP <br />LICENSE A,'C-57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION <br />DOMESTICfWELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE V Domestic/Private ❑ Irrigation/Agricultural n Industrial I I Water Quality Monitoring Li Soil 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 El Well Alteration/Modification LI Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well [l Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I I New Pump Pump Replacement ❑ Pump Repair I Raise Well Casing <br />WELL CONSTRUCTION It <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I -I 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 I_I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 1.1 Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall I.1 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D Pump Contractor ❑ Other <br />Ll Concrete Pedestal Il Dimensions: Width ft Length ft Thick in I I Christy Box I_I Stove Pipe <br />PUMP Submersible l l Turbine ! : 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 QOMPENSATION LAWS. <br />E REQUIRED FQR JNSP <br />SIGNED <br />DEPARTMENT 0-/;Z- <br />UffSE ONLY <br />`f <br />Application Accepted By Date - );Z - /V <br />Grout Inspection By Date <br />Pump Inspection By 1 Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />NS -PLEASE CALL (20941_11✓k <br />69 <br />4,4 -,DATE <br />Area :Z /S K n Employee ID# n 7 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth H <br />PE <br />Codes <br />SC Received <br />Info By <br />Check#/ <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />�- <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />