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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 /> N WREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � > • l_) CITY/ZIP �C'�Y��!"�� �� (� m <br /> � D <br /> CROSS STREET _ ��� APN D�� 32'0PARCEL SIZE,�_�D USE APPLICATION#_ s v <br /> Q - m <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP 'INWyoy/ <br /> 1 <br /> CONTRACTOR aLc f Y PHONE}� V;12_ <br /> CONTRACTOR ADDRESS PO b CITY/STATE/ZIP xv� <br /> ff <br /> SUBCONTRACTOR ,/ <br /> �CI 0 CJI' �=-� ^ I <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE2,3 <br /> 'G57 ❑ C-61 ❑ D-09 ❑ Other NUMBER/ -f EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE p'-'Domestic/Private ❑ Irrigation/Agricultural I I Industrial ❑ 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 WORK *,C.New Well ❑ Replacement Well I I Well Alteration/Modification I I Other <br /> ❑ Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings I I Geotechnical #of borings <br /> I_I Out-Of-Service Well [J Out-Of-Service Well Renewal I-I Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method e4hd Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation ! L in diameter 1J Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Schede rD ❑ Steel ><Plastic IJ Stainless Steel ❑ Other <br /> Grout Seal DepthDrD ft I l Neat Cement(94 Ib bag/5-10 gal water) Sand Cement1/0.� 2 sack mix17 gal water <br /> I_I Bentonite(20%solids) ❑ Other l" <br /> Grout Placement MethodX Pumped ❑ Free Fall I 1 Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By -0riller ❑ Pump Contractor Ll Other <br /> 17 Concrete Pedestal riDimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 11 Other HP�_ Pump Set ft Standing Water Level ft <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 /> MIRIMUM 24 MOADVANCE NOTICE REQUIRED FO,�RyIN�S.`PEECITIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED �4" � TITLE r w)' i� DATE � —�— ��7 <br /> ro 1018 <br /> 11 Fol <br /> N � U <br /> D T q�N�Y <br /> FNT <br /> 44 <br /> EP RTMENT U E/ONLY Application Accepted By Date _ t i Area Employee ID#"��47 <br /> Grout Inspection By Date 1X It Ll SPECIAL Well PerMit <br /> Pump Inspection By Date + L4 11 WAIVER Received <br /> Soil Boring Inspection BX Date Constructed Well Depth �;� ft <br /> COMMENTS (n,., <br /> c <br /> PE SC Received eckW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> d 5a 3 I <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />