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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 <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />Vj <br />JOB ADDRESSAtam <br />CITY/ZIP <br />CROSS STREET <br />APN e PARCEL SIZE <br />LAND USE APPLICATION# <br />PHONE&OU 03 -6za9 <br />OWNER NAME <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />tl[D <br />CONTRACTOR <br />PHONE <br />W <br />��L) <br />qgCONTRACTOR <br />ADDRESS <br />CITY/STATE/ZIPLNkYA!�MjSCA <br />SUBCONTRACTOR <br />A IK4 <br />PHONE i " <br />LICENSE <br />ADDRESS <br />57 EIC -61 <br />❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION DATE <br />)OMESTIC WELLS MPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) UArsenic (4393) <br />NTENDED USEtoblic <br />mestic/Private ❑ Irrigation/Agricultural ❑ Industrial E] Water Quality Monitoring El Soil Sampling/Characterization <br />Water System <br />If different from Owner: W5ter System Name L;ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) [-]Geotechnical # of borings <br />❑Out-Of-ServiceLW❑Out-Of-Service Well Renewal ❑Cross -Connection Repair <br />F-1 New Pump Amp Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] 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 [-]Steel ❑Plastic E] 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 />[-]Bentonite(20% solids) ❑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 []ChristyBox ❑Stove Pipe <br />Ae <br />PUMP it 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 />C <br />DE ARTMENT U E N L Y <br />Application Accepted By 4AAA Date <br />Grout Inspection By Date <br />Pump Inspection By u9 "-"M'4A Date \1-- <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area l Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />1 <br />m <br />D <br />0 <br />v <br />m <br />m <br />w <br />cn <br />PE SC <br />Codes Info <br />Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />B Cash Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />