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3 <br /> a <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY.ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABL PERMIT CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> UaJOB ADDRESS CITY/ZIP m <br /> / D <br /> CROSS STREET �PN . PARCEL SIZE AND USE APPLICATION# A <br /> �� m <br /> OWNER NAME PHONE <br /> _ r <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR l n PHONE <br /> CONTRACTOR ADDRESS [QIOCl�' �Q CITY/STATE/ZIP <br /> SUBCONTRACTOR VIA= PHO <br /> SUBCONTRAC OR ADDRESS CITY/STATE/ZIP <br /> AL <br /> N, <br /> LICENSE C-57 Ll C-61 11D-09 El Other NUMBER id EXPIRATION DATE <br /> DOMESTIC WELL V <br /> PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 11 Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well LI Well Alteration/Modification ❑ Other <br /> I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings s Geotechnical #of borings <br /> LI Out-Of-Service Vell LI Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I_I New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger LI Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter I_I 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 I I Steel ❑ Plastic s 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 /> Ll Bentonite(20%solids) s Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall FI Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor 1.7 Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersibles Turbine U Other HP Pump Set ft Standing Water Level Z ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W H 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 /> 1 24 UR VA CE NOTI�E REQUIRED FORI 1SPEL1=S - PLEASE CALL (209).. 3 697 <br /> SIGNED TITLE DATE <br /> PANA <br /> w Vu <br /> EA n <br /> PA E <br /> ARTMENT Ufi E ONLY <br /> Application Accepted By V Date-��/b/ Area 414 Employee IDA/ov6 <br /> Grout Inspection By mate I_ SPE IAL Well Permit <br /> Pump Inspection By �I Oil oq�(�, ' Date T1) ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> ods Info By Cash Remitted Service Request# <br /> G t <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />