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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS We S7 CrrylZIP m <br /> CROSS STREET 0 APIN V 71-�ZSIJ r� PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME S <br /> A <br /> ��JrCIO PHONE w <br /> OWNER ADDRESS 374 4 LT 1A CCA�e` CITY/STATEMP 6L. itidy CA 9!�1o7 <br /> CONTRACTOR Jl 14 , p. PHONEVq-�UyOFFF <br /> CONTRACTOR ADDRESS 1L t Wil-1 AL-4. CITY/STATE171P l4C �( ,Q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIN/STATTEJZIP <br /> LICENSE C-57 D C-61 D D-09 D Other NUMBER 7yo O 15' EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391)1.Dibromochloropropane(4392)f Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial Water Quality Monitoring 11 Soil Sampling/Characterization <br /> Il Public Water System <br /> if eiMerern from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well D Repla ment Well G Well Atteration/Modification D Other <br /> XMonitonng Well(s)=#0(wells D Soil Bonng(s) a of bonngs D Geotechnical a of borings <br /> D Out-Of-Service Well D Out-01-Service Well Renewal C Cross-Connection Repair <br /> C New Pump D Pump Replacement C Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I'Mud Rotary D Air Rotary XAuger n Cable Tool [t Push Point Ll Other <br /> Pro osed Well Depth�Q_ft I� <br /> PExcavation_�in diameter ❑Open Bottom t'11&avel Pack/Gravel SX 1(__r�0.in„diameter <br /> Fi Conductor Casing in diameter / Conductor Casing Depth /_ ry Came 'Fi NI <br /> Well Casing Diameter 9 In Thickness/Gauge/ASTM Schad 6/0 O Steel plastic 7 Stainless Steel ❑Other <br /> Grout Seal Depth 7_ft Neat Cement(94 lb bag15-10 gal water) I1 Sand Cement sack mix/7 gal water <br /> Il Bentonite(20%solids) fl Other <br /> Grout Placement Method D Pumped G Free Fall Other C Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor 17 Other <br /> ❑Concrete Pedestal[;Dimensions:Width It Length ftThick in D Christy Box D Stove Pipe <br /> PUMP D Submersible Turbine D Other HP PUMP Sel It 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> Fit <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date O SPECIAL WBII Permit <br /> Pump Inspection By Date 17 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth fl <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoke# Well IDN <br /> Codes Info B Cash Remitted Service Requestif <br /> EHD43-06 a101116 WELL/PUMP PERMIT <br />