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�V <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CAL 209 953-76Q7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />In <br />JOB ADDRESS 0 Vq d lu <br />�CITY/�ZIP <br />��/� <br />CROSS S�REET PN �O V/J PARCEL SIZE / _ "/ / LAND USE APPLICATION # <br />OWNE9AME �0� PHON <br />OWNER ADDRESS CITY/STATE/ZIP <br />1 <br />CONTRACTOR PHPNE <br />/ ��//�� <br />CONTRACTOR ADDRESS CITY/STATE/ZIP C.r—i <br />SUBCONTRACTOR PHONE A 114 <br />SUBCONTRACT R ADDRESS TY/STATE/ZIP <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />DOMESTIC ELLS MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) [-]Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial []Water Quality Monitoring ❑ Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name on ac ame or one um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) #of wells []Soil Boring # of borings s) []Geotechnical # of borings <br />❑Out-Of-Servic*umoReDlacement <br />ll ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />n New Pump n Pumo ReDair n Raise Well Casinq <br />Drilling Method E] Mud Rotary [-]Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter F] Open Bottom ❑Gravel Pack/Gravel Size <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />in diameter <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel []Plastic ❑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 />❑ Benton ite(20%solids) ❑Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal EDimensions: 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 />F_PARTM ENT IJRF NLY <br />C <br />Application Accepted B Date <br />Grout Inspection By Date <br />Pump Inspection By t h, ) Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />T <br />m <br />D <br />0 <br />v <br />M <br />m <br />Cn <br />N <br />Area Employee ID#� <br />SP CIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received heck#/ <br />Codes Info B Cas <br />Amount Permit/ <br />emitted Date Service Request #V"V Invoice # Well ID# <br />c 1'x-1 i <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />