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9 <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 CALL 209 953-769T FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />T //�y Z , <br />JOB ADDRESS `, 9 .1— ,Z, CITY/ZIP �/. V / <br />CROSS STREET YV APN / ✓✓ O PARCEL Sizm LAND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS ,/� \Ic1 �'!� ^c CITY/STATE/ZIP /�1 <br />CONTRACTOR 11 A 1JILL-�11y 1 �y ', '� �+ � �%��1 �lTl.i v 1 O PHONE 2 L/��� 210 <br />CONTRACTOR ADDRESS 2n-0 CID {+�fJl . CITY/STATE/ZIP � �)"� <br />a <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS C TY/STATE/ZIP <br />LICENSE -57 -61 ❑D-09 ❑Other NUMBER EXPIRATIONDATE <br />DOMESTIC WELL SAMPLING: ❑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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) E] Geotechnical # of borings <br />❑Out -Of -Service Well F1 Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump ipump 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 [-]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 E] 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 />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ 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 />PUMPSubmersible❑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 />c <br />TZ <br />1 <br />m <br />D <br />v <br />v <br />X <br />m <br />ur <br />ur <br />DE ARTMENT SE NLY <br />Application Accepted B Date <br />Grout Inspection By Date <br />Pump Inspection By0A A i Date t <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />M10=1111114111�- Permit/ <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />