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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />GALL ZU9 U53 --[b![ FOR INSPECTIONS t7%1jIKt S I YEAR FROM UATE ISSUED <br />JOB ADDRESS (P7`A/�Y/-'/✓SfRO2I C- <br />CROSS STREET / / ��. d A P N / /JO 7_70 *() PARCEL SIZE �' LAND USE APPLICATION # <br />OWNER NAME�/l/L�G/�/V/T- �IC j��/►/� PHONr '!/I/7/ <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 II Other <br />CITY/STATE/ZIP <br />P�HOjN,E. ��r/���,J9Zf CJ <br />CITY/STATE/ZIP -�/� er-A- <br />PHONE <br />CITY/ST <br />A <br />T <br />E/ZIP �— <br />NUMBER 00� EXPIRATION DA <br />DOMESTIC WELL SAMPLING: i i General Mineral/Coliform Bacteria (4391) i 1 Dibromochloropropane (4392) ! Arsenic (4393) <br />INTENDED USE Xomestic/Private 11 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring [_I Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />O <br />TYPE OF WORK ❑ New Well ❑ Replacement Well a Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells I Soil Boring(s) a of borings f I Geotechnical n of borings <br />❑ Out -Of -Service II ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump WumpReplacement [I Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I:I Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) 11 Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method D Pumped ❑ Free Fall I I Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor U Other <br />❑ Concrete Pedestal []Dimensions: Width ft Lenqth ft Thick _ in ❑ Christy Box ❑ Stove Pipe <br />PUMP **Submersible Cl Turbine ❑ Other HP Z— Pump Set /,YP f ft Standing Water Level <br />1 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 />MINCE NOTICE REQUIRED FOR <br />/IINSPECTIONS - PLEASE CALL (209) 953;1697 <br />SIGNED TITLE // DATE iZ Z <br />%Mr <br />D P A R T M E N T U$ E 9 N L Y HEALTH DEPARTMEtNTI <br />Application Accepted By , Date r 7 Area 6 Employee ID# r V� <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date l a I� ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received r Check# Amount <br />codes Info B as emitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />*IS? <br />�'jP00ST+2n <br />EHD43-06 8/01/16 WELL/PUMP PERMIT <br />