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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 PALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �J rn <br /> JOB ADDRESS ��• 0.�zry7 (/ �L <br /> , rh - /C CITY/ZIP m <br /> tjQ n <br /> CROSS STREET / / rOYt 44e.N/ APN (/S/i�I J/ PARCEL SIZE��,LAND USE APPLICATION#.� �f �^® �r a <br /> OWNER NAME �ap�D�i /V u✓I'P \ PHONE 53d — 2-�-�D—J.-Jj gya rn <br /> OWNER ADDRESS r CITY/STATEIZIP ` 11 C '/(.� C. ? 7 S al <br /> CONTRACTOR /60 <br /> Ga-Q� PHONE V I w <br /> �s�r ��7� <br /> CONTRACTOR ADDRESS �J D 6 0X �3 3 CITYISTATEIZIP �� �LA i <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIN/STATEIZIP <br /> LICENSE Ule 57 ❑C-61 [I D-09 ❑Other NUMBER / E%PIRATION DATE g <br /> DOMESTIC WELL SA mP :❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)[]Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name on a ame or Phone Number <br /> TYPE OF WORK E]New Well BKeplacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump El Pump Replacement E]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method N4ud Rotary El Air Rotary []Auger ❑ able Tool E]Push Point ❑ Other <br /> Proposed Well Depth�F7) ft Excavation � in diameter El Open Bottom ravel Pack/Gravel Size._—b in diameter <br /> E]Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter-40— in Thickness/Gauge/ASTMSched Zon ❑Steelastic ❑Stainless5eel ❑Other <br /> Grout Seal Depth //2ft E]Neat Cement(94 lb bagf5-10 gal water) E]Sand Cement �fl 3 sack mix/7 gal water <br /> [I Bentonite 0 lids) ❑Other <br /> Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ump Contractor ❑ Other <br /> E]Concrete Pedestal Dimensions:Width It Length ft Thick in ❑ChristyBox ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP 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 COMPENSATIO S. <br /> MINIM 4 HO ADV CE OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)9539)953 <br /> SIGNED TITLE DATE o <br /> �4 Y <br /> � I <br /> C U <br /> i <br /> C <br /> 0 <br /> L M yAMA <br /> PARTMENT USEEO� N�L.�Y� <br /> Application Accepted By Date ") / / 10/ 1 / Area _ Employee ID#I&n c o r I.�-./�V <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring IDspection By pate `Constructed Well Depth <br /> c <br /> COMMENT <br /> 4 <br /> PE SC Received Check#/ Amount Date PermiV Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> 6q a 00 0 <br /> > `OO 311U111 &K007(Pq-1 <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />