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A 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 />�wtiI:IZ�f1�ly!vJiIII,II11rADM:/ LAND USE APPLICATION # <br />CROSSiAPN PARCEL SIZE <br />OWNER ADDRESS AAA IlArq, CITY/STATE/ZIP z? <br />CONTRACTOR ADDRES CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS_ /STATE/�ZII JP <br />LICENSE C-57 ElC-61 F -1D-09 E]Other NUMBER VV/ EXPIRATION DATE <br />DOMESTIC WEL AMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USEDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br />❑ ublic 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 />E]Out-Of-Service II ❑Out -Of -Service Well Renewal [:] Cross -Connection Repair <br />E] New Pum Pum Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El 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 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑Bentonite(20%solids) ❑Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other [:]Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />F1 Concrete Pedestal dimensions: Width ft Length; ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP MSubmersible❑Turbine ❑Other HP '/o( 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 />M <br />SIGNED <br />ANCE NOTICE REQUIRED <br />DEPARTMENT U 'E O LY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By t Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />�NJS�_-PLEASE CALL (209�,9�j3-767 <br />IVI 1 DATEZ /—as -I/ <br />Area / Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Receivedh Amount Date Permit/ Invoice # Well ID# <br />Codes Info ash Remitted Service Re uest # <br />UINI�'� 5 OP00 3iC <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />Cn <br />ur <br />