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1 1 h <br />`.� '� <br />_J -s -LL <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT` 1868 EAST HAZELTON AVENUE - ST OCKTON CA 95205 - (209) 46'-3420 <br />NON-REFUNDABLE PERMIT <br />t , j <br />JOB ADDRESS U`� <br />a <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 [I C-61 <br />CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�C) I ko CITY/ZIP LtOo (11 -7 <br />/ - ° '� 0 <br />APN � S I �PARCcL SIZE LAND USE � .PPLICATION # <br />�I���,j��\y�,�// PHONE l"� I �► L (] (J _ <br />/7�,v- N " CITY/STATE/ZIP <br />aikt�n cn- <br />PHONE <br />CITY/STATE/ZIP <br />2MT,ft <br />44 PHONE <br />glTY/STATE/ZIP <br />❑ D-09 ❑ Other <br />NUMBER <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USEIN <br />Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial E]Water Quality Monitoring E]Soil Sampling/Ch c I II <br />F1 Public Water System Imic <br />If different from Owner Water System Name on ac am <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑Other40 V <br />[-]Monitoring Well(s) # of wells []Soil Boring(s) # of borings# of borings <br />E]Geote <br />[]Out -Of -Service 1 E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump 04 Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method [I Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />r. <br />L, <br />, u of,sing in diameter / Conductor Casing Depth ft <br />Wel asfng Diameter In Thickness/Gauge/ASTM Sched ❑Steel []Plastic ❑Stainless Steel ❑Other <br />j �JXe ft ❑Neat Cement (94 Ib bag/5-10 gal water) E] Sand Cement sack mix/7 gal water <br />i JL�1 n% solids) ❑Other <br />Grout Placement Method ❑Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By E] Driller E] Pump Contractor ❑ Other <br />[]Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP EVSubmersibleFlTurbine ❑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 LAWS. <br />SIGNED <br />T <br />m <br />D <br />v <br />v <br />X <br />DEPARTMENT <br />,/USSE� ONLY / <br />Application Accepted By a Date I / Area Employee ID#67�u/7 i� <br />Grout Inspection By Date f , ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring I9spection By Date L onsstrutted Well Depth ft <br />COMMENTS Ae,"SJ�ot i IPac�r4l,, i�� l r.a/� gC601is -ked, Sale ct,C�, &,Aid L/L// 664, 4111,u,.9 <br />PE Sc Received he Amount Permit/ V <br />Codes Info B a Remitted Date Service Request # I ID# <br />1 <br />% EHD 43-06 8/01/16 \ WELL /PUMP PERMIT <br />1 <br />