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WELL/PUMP PERMIT 10 <br /> SAN 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 /> n ) in <br /> JOB ADDRESS ��( �, A M41.1 CITY/ZIP sl'tg IQr� l S S 1 m <br /> CROSSSTREET �lru\v�o'�. Ira T <br /> 2z.�`�1ti0 tJ6� PARCEL SIZE b-LAND USE APPLICATION# v <br /> jp�� �7 A) _nIoQm <br /> OWNER NAME J.-�l'. fLAo I Y�l k� t-'h u� be fuo!;I � !r PHONE 83?���j� 7�� (yir <br /> OWNER ADDRESS Z S(} j �oK rT�^ 'cq CITY/STATE/ZIP [e3 <br /> CONTRACTOR masfllk br Mly,H flet <br /> PHONE 522' <br /> CONTRACTOR ADDRESS i Iii A I be e S 1`Ct CITY/STATE/ZIP/�j�`°Y 6f1 f j4-d <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST/ATE/ZIP <br /> LICENSE 2t-57 ❑C-61 ❑D-09 ❑Other NUMBER >b C L EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural 'Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: a er ys em Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F-1 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 Ad Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth Y6 ft Excavation 2-04 11 in diameter E]Open Bottom ;KGravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched R,L.S 0 'fSteel E]Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /O o ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement /U. i sack mix/7 gal water <br /> ❑Bentonite(2Y solids) E]Other <br /> Grout Placement Method Pumped El Free Fall El Other E]Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]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 /> l" c3 <br /> SIGNED 7 TITLE lY DATE Z fir" t L <br /> r <br /> Oq <br /> >' N O <br /> 'p q <br /> + � r <br /> E � RTMENT U E NLY <br /> Application Accepted By Date Z7 Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructe Well D h /tS-y ft <br /> COMMENTS —•. —�'� _ �p (i <br /> PE Sc Received Ch Amount D to Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 3 7 � � 0 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />