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WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r cn JOB ADDRESS 14CITY/ZIP m �1 y� Q j (� D CROSS STREET �4PN 4'(F7�Q / T PARCEL SIZE LAND USE APPLICATION#/ OWNER NAME PHONE I N OWNER ADDRESS CIT /STATE/ZIP / �!/✓ CONTRACTOR P ONE V �� CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: LGeneral Mineral/Coliform Bacteria (4391) i I Dibromochloropropane(4392) a Arsenic(4393) INTENDED USE ❑ Domestic/Private . Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service W II ❑ Out-Of-Service Well Renewal Ll Cross-Connection Repair 11New Pum Pum Replacement f_I Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 1-1 Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Ll Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERfiFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRE T AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORK R COMPENSATION AWS. M 4 E NOTICE REQUIRED FON PECTIONS -PLEASE CALL (209) 95 -769 SIGNED TITLE DATE Irlc 10 OQ M N D P RTMENT U E O LY Application Accepted By t Date l Area C Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By ° RUMM Date oa, ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS��Ca��Cv�. 1p O PE SC Received Check IV Amount Permit/ Codes Info B ash Remitted Date Service Request#let log?) 4140— Invoice# Well ID# <3 7 ZZ l°i BJP 00'-ZA 852- EHD 43-06 8/01/16 WELL/PUMP PERMIT