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,. WELUPUMP PERMIT <br /> AN 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 CITY/ZIP --I_ m <br /> D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> m <br /> OWNER NAME PHONE N <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE FIC-57 ❑C-61 ❑D-09 ❑Other NUMBER 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/ i ion <br /> ❑Public Water System <br /> If different from Owner Water System Name -------C—onFa—cFName or Hrione Number C!Z:�U <br /> TYPE OF WORK ❑New Well E]Replacement Well ❑Well Alteration/Modification ❑Other <br /> #of borings #of a g <br /> []Monitoring Well(s) #of wells ❑Soil Boring(s) ❑GeotechnicafwJ(lA <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair PE`R�MN/IT�ENTq`M <br /> [-]New Pum []Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary [_]Auger ❑Cable Tool [-]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> [:J Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E:1 Stainless Steel E]Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) E]Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) F1 Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> L]Concrete Pedestal dimensions: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 LAMS 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 1raNS p1,rv�;k }a Z��> 14w7 -2� <br /> PE Sc Received Check#I Amount Permit/ <br /> Codes Info By Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />