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As WELL/PUMP PERMIT r <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL M <br />CALL <br />953-7697 FPR INSPECTIONS <br />tXPIKtS 1 YEAR FROM UATE TISSUED <br />JOB ADDRESS <br />�� <br />��V/ N <br />1rn <br />I�U���� <br />,� CITY/ZIP <br />���77T <br />CROSS STREET <br />/ U� <br />t � <br />APN `�� U �I VC PARCEL SIZE •LAND <br />USE APPLICATION # <br />OWNER NAME <br />c C <br />77 <br />,/7 /p M <br />V <br />PHONE <br />OWNER ADDRESS�tlf-��', <br />"v /v/G� <br />a►�~/��CI`TY/S/TATE/ZIP- <br />CONTRACTOR <br />L <br />PHONE Z�/ `r .��� 1 JZ/l� <br />^� 1 <br />CONTRACTOR ADDRESS —i?w y� <br />`Lo/` �-I-C}1' <br />Loy- <br />1 <br />CITY/STATE/ZIP ��1 <br />I "�S�' � <br />SUBCONTRACTOR <br />{V t L') y I') ,) <br />�/yL k'1 �L1 <br />PHONE —_ <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />❑ D-09 ❑ Other <br />C <br />ITY <br />/S <br />� T <br />j(A <br />��TE/ZIP <br />/ <br />NUMBER l ,7(r'`� �%`y Z -Z EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) [_] <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) #of wells E] Soil Boring # of borings s) ❑# of borings Geotechnical F <br />Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />1�1 New Pump —IPump Replacement Fl Pump Repair L] Raise Well Casinq F <br />Ili ethod rVMud Rotary L] Air Rotary ❑Auger gjable Tool E] Push Point ❑ Other <br />PrppW Well Depth__C4ft Excavation _� in diameter El Open Bottom ravel Pack/Gravel Size " in diameter <br />[-]Conductor Casing in diameter / Conductor Casing Depth ft <br />4�11e ing Diameter L in Thickness/Gauge/ASTM Sched %� ❑Steel Plastic E] Stainless Steel ❑Other <br />G eal De th�ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑Other <br />Grout Placement Method Aumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By []Driller ❑ Pump Contractor ❑ Other <br />[-I Concrete Pedestal dimensions: Width ft Length ft Thick in [-]ChristyBox [_]StovePipe <br />PUMP Wubmersible❑Turbine ❑Other HP _� Pump Set �V ft Standing Water Level 7 J 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 />MIN U CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95��7 7 <br />SIGNED � � /�fZ G /i� I— TITLE �L C I DATE �! ` <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />�,982� Locu <br />DEPARTMENT <br />Date <br />Date <br />Date <br />Date <br />Area `� Employee ID# <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC Received <br />Info By_ Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />17 <br />- <br />/J <br />c C <br />77 <br />i'ir 'rj <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />