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WELLIPUMP PERMIT P <br />SAN JOACIUII COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUi4-REFUNDABLE PERMIT <br />GA L ZU9 953-7697 FOR INSPECTIONS LAVIRtS 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />6 <br />CITY/ZIP / S� <br />CROSS STREET <br />[[ <br />��n <br />p p <br />Of A/�PN 9�� p PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME <br />ii +G <br />Ort/d[ {/e�r1 <br />OWNER ADDRESS <br />/ <br />n�ISO <br />S GU r (T r� �r(�% <br />APHONE £ <br />CITY/STATE/ZIP O/1�IP'O7�//� ��l/ <br />CONTRACTOR <br />/ <br />Y •r li <br />^J <br />PHONE 76 S/— 4 c -1:C t7 <br />CONTRACTOR ADDRESS <br />• O <br />S, <br />CITY/STATE/ZIP /r��/oCk `e. F5,7yo <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITYiSTATEE/ZIP <br />LICENSE P/C -57 <br />1:1C-61 <br />n D-09 n Other <br />? <br />NUMBER .c� EXPIRATION DATE �J -1-119 <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private irrigation/Agricultural ❑ Industrial n Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />FYPE OF WORK Flew Well n ReDlaCement Well n Well Alteration/Modification Ll Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />rI Iyew rump a rump meplacement a rump Kepalr i i masse vveu t asing <br />WELL CONSTRUCTION <br />Drilling Method a Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool [I Push Point ❑ Other <br />Proposed Well Depth J d ft Excavation ;2 2 in diameter ❑ Open Bottom IL_- ravel Pack/Gravel Size in diameter <br />F] Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diametersin Thickness/Gauge/ASTM Sched S7eff/ Y5( mel LlPlastic ❑ StainlessSteel❑ Other <br />( <br />Grout Seal Depth ! ft El Neat Cement (94 Ib bag/5-10 gal water) 'Sand Cement 10'3 sack mix17 gal water <br />❑ Bentonite (20% solids) I] Other <br />Grout Placement Method **Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller .f9 mp Contractor Other <br />❑ Concrete Pedestal []Dimensions: 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. 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 CCMPENSATION LAWS. <br />MIN ✓N D /ANCE NOTICE REQUIRED FOR�InN,SPEC�TTIONNjY- PIL SE CALL (209)^7953-�7f697 Q <br />SIGNED p TITLE ©w 4 c1 / ' �f �— DATE 2C -/2 5- /O <br />D ARTMENT U.SE ONLY <br />Application Accepted By l/ Date ` <br />Grout Inspection By b Date L ZO <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS G%/� _ /.7,1T y ti . r3 <br />7 <br />Area Employee ID# b&o <br />LI SPECIAL Well Permit <br />Ll WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check Amount Permit/ <br />Codes I B ash emitted Date Service Request # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />