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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 />NUN-KEFUNDABLE F'ERMII <br />JOB ADDRESS <br />r <br />CROSS STREET Wit& <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR%� i <br />CONTRACTOR ADDRESS 2 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />(:ALL LUy UO3-rbUt FOR INSPECTIONS CArlKCJ -1 TEAK FKUM UAIL 155ULIJ <br />APN r 90 4_2 <br />LICENSE AC -57 IJ C-61 ❑ D-09 II Other <br />CITY/ZIP <br />ARCEL SIZE /4. q LAND USE APPLICATION # <br />HONE 47 �/1 b " L �)� <br />C <br />I <br />TY/STATE/ZIP <br />l ��`�7 rf✓�7 <br />�jVly� PHONE Lf� 9�, -✓��) <br />CITY/STATE/ZIP ( ) qa;?1, <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER <br />EXPIRATION DATE <br />DOMESTIC WELLS X <br />PILING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (43u2)1 ! Arsenic (4393) <br />INTENDED USE Domestic/Private [ I Irrigation/Agricultural ❑ Industrial ❑ 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 ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells I I Soil Boring(s) # of borings ❑ Geotechnical /# of borings <br />❑ Out -Of -Service II [i Out -Of -Service Well Renewal Li Cross -Connection Repair —V�'9-:1V <br />11 New Pum Pum Replacement Cl Pum Repair ❑ Raise Well Casing,il <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary LI Auger ❑ Cable Tool ❑ Push Point ❑ Other JAN <br />Proposed Well Depth ft Excavation in diameter n Open Bottom ❑ Gravel Pack/GraveA I meter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft H SNV/R�OUNT�, <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic I Stainless Steel �jzmmz AL <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 get water) ❑ Sand Cement sack mixNFRWITwater <br />❑ Bentonite (20% solids) f_I Other <br />Grout Placement Method I I Pumped ❑ Free Fall LI Other 1i Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP X Submersible F1 Turbine I I 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 />WORKERS COMPENSATION LAWS. <br />NIMUM 24 1H, ADVANCE NOTICE REQUIRED FO F� INSPEC IONS - PLEASE CALL (209) 953r-7 97 <br />SIGNED AMOOD,V =We"_)TITLE � DATE �1 <br />DEPARTMENT USE ONLY <br />Application Accepted By1A Date JX !� G <br />Grout Inspection By f Date <br />Pump Inspection Byot__, VW ` Date Qrik\,? <br />Soil Boring Inspection By Date <br />COMMENTS <br />MEWEMIFAVE M <br />m <br />m <br />0 <br />0 <br />O <br />m <br />m <br />y <br />Area lqq Employee ID# �ifirt <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />