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f * . 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 CITY/ZIP m <br /> D <br /> CROSS STREET APNPARCEL SIZE D' 1 II,,L,,��A,,ND USE APPLICATION#A6 q <br /> I l i� o <br /> OWNER NAME `n wrHONE _"J � m <br /> OWNER ADDRESS I D ITY/ TT(AT' <br /> CONTRACTORtj HONE02-1 D <br /> ��y�� <br /> CONTRACTOR ADDRESSJ1 r CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE 4 ) 14 <br /> SUBCONTRACTOR ADDRESS Cry/STATE/ZIP <br /> /r <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 4hmeEXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial E]Water Quality Monitoring [-]Soil Sampling/Characterization <br /> X <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 /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) ❑Geotechnical #of borings <br /> ❑Out-Of-Serviceell E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> E]New Pump 2Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method El Mud Rotary ❑Air Rotary ❑Auger [-]CableTool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom [-]Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E]Stainless Steel El Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) F]Sand Cement sack mix17 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 /> ❑Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set L>' 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 /> r <br /> If I M 4 H A NCE NOTICE REQUIRED IF - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE=- DATE <br /> E+ <br /> In F S,N 17;. .Uti IN CC LN <br /> E <br /> �J <br /> e` <br /> DE ARTMENT USE/ONLY <br /> %pp.;cation ;urep[eo Sv : I/ c Mate /-1A.-e_�7 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date [] WAIVER Received <br /> Soil Boring Ins ection By Date _ ConstrucieUi ;v4-il uepth ft <br /> COMMENTS v " c�rC!i�✓.7C✓ - a.,;, <br /> eco"t c /Y9 n r <br /> < < 's- - T u ­/r�nJk- <br /> PE 3C Received Check#/ Amount Perm*17 <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />