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_ JnVMIScan q/13/17 947 <br /> WELL/PUMP PERMIT Nh'"2. <br /> Zy <br /> SAN JOA,.IUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205�- (2I 9)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �:Sq-)I CITY/ZIP +��II,G ak� C A m <br /> T� <br /> CROSS STREET APNj� �1 —2_ 0 72/, PARCEL SIZE HONE LAND USE APPLICATION 1#` <br /> OWNER NAME O[Q G J�Y�c+ \ $ I(h V�J'I� f j /lP, 2014 IS-0-0 N <br /> OWNER ADDRESS L����m e1�� CITY/STATEIZIP <br /> CONTRACTOR S + 4 Ci /-PHONE <br /> CONTRACTOR ADDRESS�_D�V�, CITY/STATE/ZIPC`,] 64 � 'vr�C��S�L 4i <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 E]Other NUMBER 4470-76 b EXPIRATION DATE tin 1 <br /> DOMESTIC WELL SAMP G:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well 424placement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑ #of borings Soil [-]Geotechnical #of borings <br /> F1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> et <br /> Drilling Mhod ud Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth 3 cro ft Excavation Z/ in diameter ❑Open Bottom ravel Pack/Gravel Size�Z-4 in diameter <br /> ❑Conduc=hickness/Gauge/ASTM <br /> in diameter / Conductor Casing Depth ft — <br /> Well Casing Diameter Sched 21,1 ❑Steelas is El Stainless Steel ❑Other <br /> Grout Seal Depth " /� El Neat Cement(94 Ib bag/5-10 gal water) and Cement A),3 sack mix/7 gal water <br /> ❑Bent ite ° olids) ❑Other _ <br /> Grout Placement Method umped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> F]Concrete Pedestal[dimensions:Width ft Length ft Thick in ❑Christy Box ❑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 COMPENSATION L S. <br /> MINIMU ADVC OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95?-7697 <br /> SIGNED TITLEDATE / 7 <br /> r <br /> t 1t� J 'AC UI NM�N �1' <br /> � T <br /> , <br /> c <br /> DEPARTMENT USE ONLY <br /> Annlicatien Accented By _ _ Data r Area EmDlovee ID# <br /> Grout B �"SInspection � ` <br /> � p y Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> cam' <br /> Soil Boring Inspection By Date Construe ed Well Depth ft <br /> COMMENTS GAJ Z _C (fl! <br /> r I <br /> PE SC Received Check#/ Adifunt Permit/ <br /> Info B Date as Remitted Service Request# Invoice# Well ID# <br /> IVI h <br /> 8/01/16 WELL/PUMP PERMIT <br />