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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 /;, CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET On <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />CITY/ZIP <br />APN O PARCEL SIZE LAND USE APPLICATION # <br />PHONE ��Q .�Jt <br />CITY/STATE/ZIP <br />AIK__�09 C49 HONE <br />n CITY/STATE/ZIP ?5-1 <br />PHONE <br />SUBCONTRACTOR ADDRESS I (;ITY/STATE/ZIP /�j <br />LICENSE C-57 [IC -61 F -1 D-09 E] Other NUMBERqffV La EXPIRATION DATE ✓ <br />DOMESTIC ELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name L;ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well [:]Well Alteration/Modification ❑ Other <br />❑Monitoring Wells) # of wells El Soil Boring # of borings s) ❑Geotechnical # of borings <br />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary El Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ 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 ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />E] Bentonite (20% solids) F-1 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />[-]Concrete Pedestal Epimensions: Width ft Length- ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑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 COMPENSATION LAWS. <br />SIGNED <br />LEPARTMEN�1 <br />Application Accepted By Date T SE NLY <br />Area Employee ID#aj- <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By I Date ❑ WAIVER Received <br />Soil Boring Inspection By ` Date Constructed Well Depth ft <br />COMMENTS N 1 4 cce' o to ck e <br />T <br />1 <br />m <br />v <br />v <br />rn <br />m <br />N <br />PE SC Receive Check#/ Amount Permit/Codes Info B ash Remitted Date Service Request # Invoice # Well ID# <br />©►sgto 1,9 ► , ,P �� <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />