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t <br />- ' WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT (.:ALL ZUy U0.5-/tiy/ FOR INSPECTIONS tAl`IKtJ 'I TEAR FROM DATE ISSUED <br />'� <br />JOB ADDRESS �/1� �,� L142 <br />R`n5T, t, A-, CITY/ZIP GSC � Z 42 <br />CROSS STREET A P N Z�Gq— Ql 0 -1-3?--PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME ra,d 1. ��2yL/nc PHONE <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR /V &A - /'%-� �JPHONEE ,,7p f! <br />—//CiS - 7, ? <br />l 7V <br />CONTRACTOR ADDRESS r : (� ��»r' d `'`� CITY/STATE/ZIP '14 Kq' L'r— <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 <br />C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER ; 76�5�1 EXPIRATION DATE S_ _,?Q <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 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: <br />Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other Vh <br /># of borings o �}ps <br />[i Monitoring Well(s) # of wells a Soil Boring(s) ❑Geotechnical �/ fV/�� <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />`� iY New Pump ❑ PUrT1D Replacement ❑ Pump Repair LI Raise Well Casing <br />YYGLL I+VIVJ I KW, I IUIV--,'7/yJ -.w <br />Drilling Method El Mud Rotary 11 Air Rotary 11 Auger ❑ Cable Tool L' Push Point [.1 Other FN/O�AQV/NC <br />Proposed Well Depth ft Excavation in diameter [I Open Bottom ❑ Gravel Pack/Gravel SizA' D"P diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft " HENT <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic I I Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other Il Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />X1 PUMP Submersible El Turbine ❑ Other HP Pump Set ft Standing Water Levelft <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 />MINI UM 24 HOUR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697(/ <br />IGNED W."t/L�.L ��G/t-� (�� TITLE (1C�f�t/T.1P ✓f Y. �J IJ DATEyC ' t 7g <br />Application Accepted By <br />Pump Inspection By <br />Date <br />Date 0 <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS _ <br />PE Sc Received Che Amount <br />Coe Info B Cas emitted <br />Permit/ <br />Date Service Request # Invoice # Well ID# <br />20 Qc-379Lci <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />