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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 /> Ln <br /> JOB ADDRESS CITY/ZIP )� J U 0 , ", lf/ f <br /> 11 ,^, u 'a m <br /> CROSS STREET AP W (� ��V u PARCEL SIZE I ) LAND USE APPLICATION# A <br /> m <br /> OWNER NAME c ( PHONE vi <br /> OWNER ADDRESS l ` y % / i CITY/STATE/ZIP �Il�" <br /> CONTRACTOR A- r <br /> h J r,,o►r ) y� PHONE <br /> CONTRACTOR ADDRESS O � c dAADS L\ T 1 0,(//1� CITY/STATE/ZIP C) <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE E47C-57 ❑C-61 ❑D-09 ❑Other NUMBER 00 EXPIRATION DATE <br /> DOMESTIC WELL 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 Uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells #of borings Geotechnical�#of borings <br /> E]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pum Re air ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary ❑Air Rotary [$Auger El Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth I`- --A�;- ft Excavation & in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F-1 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 10 ft , Veat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) fQther I r 1 ' `. <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 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 /> MIfN�M�M24HU CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED ri / TITLE r 4e DATE 7 l� <br /> v <br /> Oq lg <br /> R <br /> T <br /> PA TMENT U E CNLY <br /> r <br /> Application Accepted By Date �( Area ( Emplovee ID# <br /> Grout Inspection By ,v Date 1 ❑ SPECIAL Well Permit <br /> 100, <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Permit/ <br /> Codes Info By, ash-/- Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />