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WELL/PUMP PERMIT <br />SAN JVAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDA13LE rEERMIT UALL [ yb3-1bU FOR INSPECTIONS LAVIK11=5 'I YEAR FROM DATEjISSUED <br />JOB ADDRESS 6AO LcL CITY/ZIP j `]� ja( <br />CROSS STREETy� APN L DS 2. 2n�' . S PARCEL SIZE LAND USE APPLICATIIO�NQ#% /^ e <br />sOWNER NAME )�IL _"' 1�D �r� ��/ ��C- �\nPHONE I(JFJ� 1(o <br />OWNER ADDRESS 3a 55 11V M gt, Ja s CITY/STATE/ZIP_ Z � 7 <br />i <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE [I G-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER I/ / �- <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural VrIndustrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name ------ C-o—nfact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification E] Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑Out -Of -Service ell [:] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump APump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] 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 />F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) []Sand Cement sack mix/7 gal water <br />❑ Bentonite (20%solids) F1 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 Submersible ❑Turbine (-]Other HP J(J 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 />MINI �//�U �NCE N�OiTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95? -7097 <br />SIGNED_�'`r%� L�GZ✓S/ "K��� TITLE ef/!�/r DATE <br />DEPARTMENT U E ONLY <br />Application Accepted By Date !� 1 <br />Grout Inspection By Date <br />Pump Inspection By , Date {� <br />Soil Boring Inspection By <br />COMMENTS 3;YNG n tea. <br />1,aie <br />T <br />1 <br />m <br />v <br />v <br />m <br />m <br />U) <br />Area 99 Employee ID# i2C-5 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />WPII r)Pnth <br />PE Sc Received Check#/ Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Cash Remitted Service Request # <br />r - <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />