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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 />JOB ADDRESS 1 .4 i7( -/f Z �/ / C / C-- <br />CROSS STREET APN .42 f= <br />OWNER NAME rte, 1F;1r14 <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />_. CITY/ZIP <br />PARCEL SIZE BLAND USE APPLICATION <br />0119 PHONE ;20 <br />S/D / CI /STATE/ZIP Z%A' �i•/ <br />CITY/$TATE/ZIP <br />PHONE <br />ADDRESS _ _ CITY/STATE/ZIP <br />LICENSE )e-57 ❑ C-61 ❑ D-09 [] Other NUMBER /� y�l EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE kDomestic/Private ❑Irrigation/Agricultural El Industrial [I Water Quality Monitoring ❑Soil Sampling/Characteri <br />zation <br />[] Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK � New Well El Replacement Well ❑Well Alteration/Modification 11 Other <br />[] Monitoring Well(s) *ofwells ❑ Soil Boring(s) #ofborings [] Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal [] Cross -Connection Repair <br />0 New PUMD ❑ Pump Replacement ❑ Pumo Reoair n Raise Well Casino <br /># of borings <br />WELL CONSTRUCTION <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, <br />Drilling Method <br />k Mud Rotary ❑ Air Rotary [] Auger ❑ <br />Cable Tool ❑ Push Point <br />❑ Other <br />Proposed Well <br />Depth6T) ft Excavation /_Z <br />in diameter <br />❑ Open Bottom 11Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / <br />Conductor Casing <br />Depth <br />ft <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched <br />0 Steel <br />❑ Plastic ❑ Stainless Steel ❑ Other. <br />Grout Seal <br />Depth=ft ❑ Neat Cement (94 <br />lb bag/S10 gal water) <br />❑ Sand Cement sack mixl7 gal water <br />X Bentonite (20% solids) ❑ Other <br />Grout Placement Method X Pumped [] Free Fall ❑ Other <br />❑ Retardant / Accelerator (name) <br />PEDESTAL <br />Installed By ❑Driller/A Pump Contractor <br />[] Other <br />❑ Concrete Pedestal []Dimensions: Width <br />ft Length <br />ft <br />Thick in 0 Christy Box [] Stove Pipe <br />PUMP <br />❑ Submersible[] Turbine ❑ Other <br />HP <br />Pump <br />Set ft Standing Water Level ft <br />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 />WORKEFS%COMPENSATION LAWS.jo <br />SIGNED <br />NOTICE REQUIRED FOR IN CTIO S -PLEASE CALL (209) S <br />TITLE DATE 1' <br />T <br />.A �UIV7Y <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring InspectionB <br />COMMENTS AJn GWN WMA <br />V <br />A <br />r <br />MENT U O LY <br />.bate <br />Date <br />Date <br />Date <br />Area_��7�� Employee ID# j t <br />❑ SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />EHE) <br />ii?,(1��1��7►1//.i!��fJ,L���S��i+7�'1IL�Jl���'/i'�1I7� <br />MAI <br />WFOIZIINA <br />Sm <br />RUM <br />4306 revised 4/74/18 <br />WELL/PUMP PERMIT <br />