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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> _m <br /> JOB ADDRESS CITY/ZIP <br /> �CROSS$TREE APN t 9r2 `�`PAL SIZE LAND USE APPLICATION# <br /> m <br /> OWNER NAME PHONE <br /> OWNER <br /> lye, <br /> OWNER ADDRESS ft"A AA CITY/STATE/ZIP <br /> . 9535D <br /> CONTRACTOR ONE <br /> CONTRACTOR ADDRESS ICZK CITY/STATE/ZIP g <br /> SUBCONTRACTOR/CONSULTANT A \ PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS TY TATE/ZIP <br /> LICENSE57 E1 C-61 ❑D-09 0 Other NUMBER EXPIRATION DATE <br /> BILLING PAR 0 OWNER 0 CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS X <br /> PLING:❑General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE Domesfic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #ofwells u Soil Borings) #ofbodngs 0 Geotechnical 41 of bodngs <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump $4-pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑Air Rotary ❑Auger n Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller 0 Pump Contractor 0 Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible0 Turbine 0 Other HP Pump Set ft Standing Water Level It <br /> I HEREBY CERTIFY THAT 1 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 COMPS SATIOV�LA <br /> MI �9OU CE NOTICE REQUIRED FOR IN E�CJTIONS-[PLEASE CALL(209)9537,769 <br /> SIGNED TITLE �%G � \ DATE 7 <br /> Ir <br /> Nr <br /> FD <br /> DE ARTMENT USE ONLY HFOIyM Uly7, <br /> Application Accepted By Date��� Area_�� Employee <br /> Grout Inspection By Date ❑ SPECIAL Well Permit NT <br /> Pump Inspection By t Z0 V Date Jl!e_J.L ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck;f/ Amount at Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> q381 0 20 4 0 ta t <br /> EHD 43-06 6111!1019 WELL/PUMP PERMIT <br />