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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn JOB ADDRESS CITY/ZIP m D CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o m m OWNER NAME PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITYISTATE/ZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name on ac ame or one Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other F1 Monitoring Well(s) #of wells El Soil Boring #of borings s) El Geotechnical #of borings ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑PUrnp Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary El Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other Proposed Well Depth ft Excavation in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other []Concrete Pedestal Lpimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE DATE q UIV Eq -rig E T M DE P n RTn1 ` NT USE 0NLY Application Accepted By Date Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash Remitted Service Request# EHD 43-06 8/01/16 WELL/PUMP PERMIT