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y. <br />WELL/PUMP PERMIT <br />SAN �OAQUINOCOUNTY 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 ), i(iV VI'111�V 7 CITY/ZIP <br />CROSS STREET L.N(/`(/n�(/ <br />OWNER NAME V V k <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />APNL�PARCEL SIZE C' VLAND USE APPLICATION/# <br />�n PHONEZ�- 46;9 <br />LICENSE )%-57 [_1 C-61 F-1 D-09 [I Other- NUMBER—LL/Uy [( U EXPIRATION DATE I <br />DOMEST16 WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USEDomestic/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 />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑Out -Of -Service W II ❑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 E] Air Rotary ❑Auger ❑Cable Tool E] 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 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 Epimensions: Width ft Length ft Thick in ❑Christy Box [-]Stove Pipe <br />PUMP Submersible❑Turbine ❑ Other HP �d r/e1 Pump Set ft Standing Water Leveler 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 LAVA. <br />MINI U CE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)/953-76G97 <br />SIGNED TITLE Gf_� DATE <br />7- <br />DEPAILIATMENT USE ONLY <br />Application Accepted ByBate <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />Area Employee ID#L�C? <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC <br />Codes Info <br />Received <br />Cash <br />Amount Date <br />Remitted <br />Permit/ <br />Service Request # <br />Invoice # Well ID# <br />42&f; <br />C`>t�—ISO <br />6-1� <br />j. -1 � <br />VY D (0 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />