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i,✓- Z:c9 (;� lvf'q►�' <br /> -a'q, 3'cr' WELL/PUMP PERMIT <br /> SAN JOAQIIIN'COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR ROM DATE ISSUED <br /> nn `' to <br /> <'' �� �/� �` CITY/ZIP ���YEP <br /> /� ��Zl�+� m <br /> ,JOB ADDRESS _ <br /> r ROSS STREET��C, /!G' '� APN �[)(/��7 U�� / PARCEL SIZE LAND USE APPLICATION# m <br /> OWNER NAME /! �5' nl,�_ rj ��I PHONE (")�lJq �L <br /> OWNER ADDRESS /ham' I `� � � G� CITY/STATE/ZIP S I��In �I CA t <br /> tcJ <br /> CONTRACTOR //,����' ��r '/�C 1 PHONE <br /> �� /�5 l t=om <br /> CONTRACTOR ADDRESS) ✓—le CITY/STATE/ZIP �'✓ �/� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE , G-57 E]C-61 ElD-09 ❑Other NUMBER,') EXPIRATION DATE f r fi F <br /> DOMESTIC WELL SAMPLING:®General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)[]Arsenic(4393) <br /> INTENDED USE ,gpomestic/Private ❑Irrigation/Agricultural ❑Industrial [-]Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> ���IIf f'''different from Owner Water ys em ame Contact Name or one um er <br /> TYPE OF WORK yglvew Well ❑Replacement Well E]Well Alteration/Modification E]Other <br /> 1 #of borings #of borings <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) []Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> J�.New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary ❑Air Rotary ❑Auger [:]CableTool E]Push Point ❑ Other <br /> Proposed Well Depth 77— _ft Excavation �L n diameter _]Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched '7_'?? ❑Steel lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth j ft ❑Neat Cement(94 Ib bag/5-10 gal water) .Sand Cement �i � sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement MethoqA Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller [:]Pump Contractor ❑ Other <br /> El Concrete Pedestal❑dimensions:Width 4=1ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP -;;4 ❑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 /> MINIMdJM 4 H // R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769/7 <br /> SIGNED �� t TITLE �I A DATE/- ' �! <br /> .J3 <br /> J <br /> J <br /> Fill <br /> 4 r <br /> UN p N <br /> AL <br /> ncvAnTMFNT t! SF nN V q 14EALTHDEPARTME(�-i, <br /> Application Accepted B Date �� ZO 1 Area R_0 Employee ID# <br /> Grout Inspection$ / Date r ❑ SPECIAL Well Permit <br /> Pump Inspection By �'' <br /> ID �ZI2V(��' ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS r L, <br /> plfvc-fz*VQj5r-Tr- M E:0 - ,qtr-tea TkriiT <br /> E SReceived Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BX_ Cash Remitted Service Request# <br /> 20 7 <br /> p�0 ► 3 3�'� D.''' 3 cS 12[)0 <br /> b 1311(, 200 7 2'4 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />