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Ik <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE TON AVENUE-STOCKTON Ci4 9 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS v/C. TY/ZIP m <br /> D <br /> CROSS STREET APND �� PARCEL SIZE LAND U�/jS�EE APPLICATION# S <br /> OWNER NAME /0�� PH��JE <br /> OWNER ADDRESS < / CITY/STATE/ZIP �- <br /> 0 <br /> CONTRACTORH NE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACT ADDRESS 7r—A TY/STATE(ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTI WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) 1 Dibromochloropropane(4392) I_ 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 System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well I:1 Well Alteration/Modification ❑ Other JOA I <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ GeotechnicalO' gelvr <br /> 11 Out-Of-Service Well [i Out-Of-Service Well Renewal 11 Cross-Connection Repair � C�'vC <br /> ❑ New Pump NdfPumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> �Drilling Method Li Mud Rotary ii Air Rotary El Auger Ll Cable Tool L Push Point 11 Other JOA r,, <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom 11 Gravel Pack/Gravel y�x9Lr/, CN "er <br /> 11Conductor Casing in diameter / Conductor Casing Depth ft `pTM G <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched 11 Steel 11 Plastic -1 Stainless Steel F1 Other FNT <br /> Grout Seal Depth ft n Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method F1 Pumped Cl Free Fall F3 Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box fl Stove Pipe <br /> PUMP ubmersible❑ Turbine n Other HP Pump Set ft Standing Water Level ft <br /> 11 <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 /> MH VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953- 6 <br /> SIGNED TITLE // A0//�` DATE <br /> IM . 1111 . 1111 <br /> D A US N L Y <br /> Application Accepted By Date / Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ti Date LJ WAIVER Received <br /> Soil Boring Ins a tion By Date Constructed Well Deppthha� ft <br /> COMMENTS iL ��� 6� ld�. LI ;rE:21C suw <br /> PE SC Receivedleek Amount Date Permit/ Invoice# WellID# <br /> Info Cash emitted Service Request# <br /> 10 P <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />