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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 j2�09 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> // Q I J . �vG1 CITY/ZIP 1 � - <br /> fr,J08 ADDRESS m <br /> D <br /> CROSS STREET r APNPARCELS LAND USE APPLICATION# o <br /> \ L�j � <br /> OWNER NAME ,r > -- r 1 `I • �� PHONE•—% /V ! /`�� of <br /> OWNER ADDRESS /' ✓�S CITY/STATE/ZIP <br /> FEW <br /> CONTRACTOR _ : �. '/ PHONE <br /> CONTRACTOR ADDRESS �}C ��c� CITY/STATE/ZIP G L- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE .><C-57 ❑C-61 ❑D-09 ❑Other NUMBER 327%gs EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private rigation/Agricultural [:]Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name Gontact Name or Phon=er <br /> TYPE OF WORK ,% New Well E]Replacement Well ❑Well Alteration/Modification E]Other 7 U C <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> XNew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>;;rMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth•C) ft Excavation L 2— in diameter ❑Open Bottom ',Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6— Thickness/Gauge/ASTM Sched�2 X) ❑Steel )4'hlastic El Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped E]Free Fall ❑Other E]Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width � ft Length ft Thick - in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Z-- 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 /> ZMINIUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNEDit_ TITLE /j(LJia h.- DATE r <br /> a <br /> n <br /> EINC UN <br /> THD ,L <br /> UE Ah( f IYIEIV IJE NL Y <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By !YI Date C� ❑ PECIAL Well Permit <br /> Pump Inspection By ��� Qkr � Date L. 't� f 1 1 E] WAIVER R@C@IVed <br /> Soil Boring Inspejtion By Date Co trusted Well pth r7 S ft 1 <br /> CO MENTS r e <br /> PE SC Received Amount Permit/Codes Ifo B Cash emitted Date Service Request# Invoice# Well ID# <br /> � r <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />