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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 53-7697 FOR INSPECTIONS (EXPIRES 1 YEAR FROMDATEISSUED <br /> L <br /> JOB ADDRESS I(/� CITY/ZIP &� � / 5 3y <br /> M <br /> 'J _ Q t D <br /> CROSS STREET , (k- ( APN �� -"o�O I PARCEL SIZE I J•�� LAND USE APPLICATION# <br /> _ '^ / C C h( 7 y <br /> OWNER NAME y / f L —+ PHONE V J � <br /> { <br /> w <br /> OWNER ADDRESS O 1 v^ }� ' K—C, C's a CITY/STATE/ZIP ( � <br /> CONTRACTOR V'-It'C— PHONE <br /> CONTRACTOR ADDRESS O >��C tL, 1 CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP l <br /> LICENSE -57 [:1 C-61 [j D-09 [:1 Other NUMBER 0I) EXPIRATION DATE {�J' <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural [:]Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> # <br /> ❑Monitoring Well(s) #of wells ❑ #of borings of boringsSoilBoring(s) Geotechnical <br /> E)Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Co ection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method [94ud Rotary _ ❑Air Rotary Luger [-]Cable Tool F1 Push Point ❑ Other <br /> Proposed Well Depthb2 ft Excavation - L# in diameter [-]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 [,�'�leat Cement(94 lb 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 /> E]Concrete Pedestal EDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑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 /> WORKERS COMPENSATION LAWS. <br /> �{ 9-H64"Ml IMUM OUR DV`A�JN, E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209) 953-7697 <br /> "C vSIGNED ✓ �� TITLE </ �)1tJ DATE 0 <br /> E ^ OTi9Eki USc roLY <br /> •" <br /> G <br /> Application Accepted By Date Area fell <br /> mployee ID# <br /> �t� <br /> Grout Inspection By Date *0SPECIALV Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By .fd1Ccr— Date A/ f 2e Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck#/ Amount Permit/ <br /> Codes Info By s em'tted Date Service Request# Invoice# RECENED <br /> OC 12 9 2018 <br /> EALTH DEPARTMENT <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />