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eT Iw '�cm ����) ��� 1 <br />-,WELL/PUMP PERMIT h %��rfi - 3 -eq <br />SAN JOAQUIN C1*'i4T'9" & VIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUPJ-KEFUNDABLE PERMIT GALL (ZU9) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />2 7, Ir r/��%(�J�/ CITY/ZIP <br />45'/ 01� APN h L —I UJ �—PARCEL SIZE ®� LAND U E APPLICATION # <br />PHONE�� <br />CONTRACTOR <br />l / <br />/I/L PHONE <br />CONTRACTOR ADDRESS <br />< cr{/ AIIL—` �T/ij <br />I'^� <br />CITY/STATE/ZIP Zf—S <br />SUBCONTRACTOR <br />I <br />o : <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE VC -57 WC -61 ❑ D-09 ❑ Other NUMBER & � /0 Z8' EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Momestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner Water System Name Uontact Name or Phone Number <br />TYPE OF WORK4Vew Well ❑ Replacement Well ❑ Well Alteration/Modification El Other <br />/❑ Monitoring Well(s) # of wells [:]Soil Boring(s) # of borings ❑ Geotechnical # or borings <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />F-1 New Pump rl Pump Replacement F1 Pump Repair 17 Raise Well Casino <br />Drilling Method/lud Rotary ❑Air Rotary []Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth Z ft Excavation / Z_ in diameter ❑ Open Bottom .ravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thi kn sGauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel E] Other <br />Grout Seal t�--- Neat Cement (94 lb bag/5-10 gal water) )Aand Cement �r'r > sack mix/7 gal water <br />r <br />❑ Bentonite (20% solids) ❑ Other <br />Grout rent Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑Driller jpump Contractor ❑ Other <br />F-1 Concrete Pedestal Lpmm 5nsions: Width _ ft Length ft Thick = in [-]Christy Box ❑Stove Pipe <br />PUMP Wubmersible❑Turbine ❑Other HP ___� Pump Set % Z!I ft Standing Water Level <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 R E NOTICE REQUIRED FOR INSPECTIONS - LEASE CALL (209) 953-,697 <br />SIGNED TITLE r P DATE <br />s <br />D E P A R <br />ie <br />Grout Inspection By <br />Pump Inspection By 1 <br />Soil Boring In <br />COMMENTS i <br />TM ENT USMENLY /y -Date E]SPECIALWell Permit.Date�/ ❑ WAIVER Received <br />Constt:ucted Well Depth <br />T <br />ft "- <br />c,cr✓" <br />PE Sc Received Check#/ Amount <br />Codes Info By Cash Remitted <br />Date <br />Permit/ Invoice # <br />Service Request # <br />Well ID# <br />1 ' 6- ° <br />a <br />77a C1 <br />003W0 -) <br />C <br />I <br />o : <br />X03 $ vil;2 <br />a�. <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />6lhu'L <br />