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S <br />44 <br />WELL/PUMP PERMIT '1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT UALL (ZU9) 953-7697 FOR INSPECTIONS % fEXPIRES��1 YEAR FROM DATE ISSUED <br />Job ADDRESS Wit- <br />` L I 5._ ��� i U' Ave y CITY/ZIP RIT (.." l Ci x'53 kk <br />Wi <br />CROSS STREET pP' + i.ID %� i� • APN _2� �' �y 61 a PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAMEy Per nd1tPes PHONE <br />OWNER ADDRESS P-() . CITY/STATE/ZIPLn 44 o -& P I CJ q�5� ' <br />3 6 <br />CONTRACTOR �r yQis I 1 (� > T%}} ��C.� PHONE_- I ei 2-b - <br />CONTRACTOR ADDRESS `' / I �t T 1 jt V CITY/STATE/ZIP 1 �` �` o�L <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE -KC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER (aL4&;k 2_Z— EXPIRATION DATE y_ 3�- <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private lKrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name uontact Name or Phone Number <br />TYPE OF WORK XNew Well ❑ Replacement Well <br />❑ Monitoring Well(s) # of wells <br />F-1 Out -Of -Service Well <br />New <br />ent <br />❑ Well Alteration/Modification El Other <br />❑ S011 Boring(s) # of borings <br />❑Out -Of -Service Well Renewal <br /># of borings <br />❑Geotechnical <br />❑ Cross -Connection Repair <br />Nasse vveu uasl <br />Drilling Method XMud Rotary El Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth C'a"3 ft Excavation 20 in diameter ❑Open Bottom NGravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter i-:2, in Thickness/Gauge/ASTM Sched '7_c�� ❑Steel y?lastiC F1 Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag15-10 gal water) Ksand Cement 1/0 � 3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method WPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By E] Driller X.Pump 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 COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED C `1 TITLE / r f i�F! DATES <br />G <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />DEPARTMENTUSEONLY <br />Date <br />Date Ld <br />Date <br />c <br />P IIKe <br />TL <br />1 <br />m <br />0 <br />O <br />m <br />m <br />or <br />ca <br />Area Employee ID#_� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date , Constructed Well Depth 2V5 ft <br />COMMENTS �� �4r�,»ir► �vf��e �,t2L� a <br />PE <br />Codes <br />Sc Received Amount Dae <br />Info By Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Reques # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />