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-OW SW <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 FROM DATE ISSUED <br /> JOB ADDRESS 1 "� {{rmin,��)�-�^ CITYIZIP' S(Li 1 a n r^ �S z` m <br /> a.G n <br /> CROSS STREET I�yuY InwY APIN - ~OSO -Cq PARCEL #>:APPLICATION <br /> [� vay e }C3 PHONE (L LL N 2- N <br /> OWNER NAME ��{ n-- <br /> '` q 7 - <br /> 'OWNER ADDRESS I c�'f7'� " �''1 CITYISTATEIZIP [— Cct I G�1 / 0, !S3� <br /> CONTRACTOR yy 11 '( I}VL� PHONE 6 2-Z/' Lei 11b <br /> CONTRACTOR ADDRESS i � l be r s ztt CITYISTATEIZIP e � / L- cf 53 5 71 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATEq—r 3 d� <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> [❑Public Water System <br /> If different from Owner: Water System Name uortacl Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification [I Other <br /> El Monitoring Wells} #of wells ❑ of borings Soil Boring(s) ❑Geotechnical #of borings <br /> 71 Out-Of-Service WeII E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pume Repair ❑Raise Well Casio <br /> WELL CONSTRUCTION <br /> Drilling Method')KMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth :34p0 ft Excavation /// in diameter ❑Open Bottom -['Gravel Pack/Gravel Size. in diameter <br /> ❑Conduct r Casing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2g=2 [j Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 1�ar ft ❑Neat Cement(94 1b bag15-10 gal water) [-]Sand Cement sack mix17 gal water <br /> Bent nite(200/c solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By []Driller ump Contractor ❑ Other <br /> ❑Concrete Pedestal Epimensions: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. l 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 /> MIPPUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED <br /> t—t��r TITLES' DATE 3 2--7-17 <br /> ' $ 1 <br /> °i 6 <br /> N <br /> 10 <br /> .r Oil <br /> O A <br /> EP RTMENT U E ONLY Af-�Wv\t~ <br /> r it <br /> Application Accepted Date fir! Area �flEmployee ID91AIi <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ttheck Amount Date Permit) Invoice# Well ID# <br /> Codes Info Remitted Service Request# <br /> EHD 43-D8 81D1116 WELL!RUMP PERMIT <br />