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L <br /> WELL/PUMP PERMIT <br /> cAN 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 /> 1�` 1'1Q ��c1 `,J(p m <br /> JOB ADDRESS L 0 CITY/ZIP m <br /> 5- APN 6o-i� <br /> CROSS STREET //�� PARCEL SIZE j Q�LAND USE APPLICATION`r# <br /> OWNER NAME clan -nP 6"A-:1 Y y-moaa\ C cnkY' �� C�t_a�A���� 5 GPHONE S�S_�'f�� X Cn <br /> OWNER ADDRESS le Z Zy S�c� �tY F� CITY/STATE/ZIP dSc��-n, CA ("�L <br /> CONTRACTOR 'e S. QY O . C• PHONE 54a -11 <br /> CONTRACTOR ADDRESS `-G d(� It C➢. CITY/STATE/ZIPbC9C-54 '0, Ca a S 3 S <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP C p <br /> LICENSE C-57 ❑ C-61 L] D-09 (I Other NUMBER 2-90 13 EXPIRATION DATE .) -3 )- 1 CJ <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) i I Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural ,ndustrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well 11Replacement Well [I Well Alteration/Modification F1 Other <br /> El Monitoring Well(s) #of wells [I Soil Boring(s) #of borings F1 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Rotary ❑ Air Rotary 11 Auger 11 Cable Tool ❑ Push Point El Other <br /> tAlf <br /> Proposed Well Depth ft Excavation 12— in diameter ❑ Open Bottom XGravel Pack/Gravel Size(,,JO. � in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Q— in Thickness/Gauge/ASTM Sched SD Q a% ❑ SteelPlastic 11Stainless Steel LlOther <br /> Grout Seal Depth�@'Q ft 11Neat Cement(94 Ib bag/5-10 gal water) Sand Cement l� .3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> IPEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> F1 Concrete Pedestal F1 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 COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE RE UIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7//697 Q <br /> TITLE >�, DATE <br /> N 4 <br /> I <br /> O tt <br /> S p ,RJi .N A <br /> VT O <br /> DEPART IMENT USE ONLY <br /> Application Accepted By Date Area 3l� Employee ID# <br /> Grout Inspection By / Date Ll SPEC ell Permit <br /> Pump Inspection By Date E-1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth �� ft <br /> COMMENTS if� pg/7 AA•Yl 1I1 LQ 0-41 '1>1 r LLA y7feC4 <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />