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-ini lW ROO � ���� �� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN G► NT L'~VIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT UALL (LU9) UbJ-tb9[ FOR INSPECTIONS tAF'IKtb 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />29 V7 f�r CQ ze, L A& -444w -'W CITY/ZIP -, c <br />AP�Nj —t `�21PARCEL SIZE ©� LAND U E APPPLIICCATION #Q� �1 <br />PHONE <br />CONTRACTOR ADDRESS �lZ10 <br />AV/ <br />/4"—Lr 4,/ � CITY/STATE/ZIP_ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />❑ D-09 ❑ Other <br />CITY/S—QT7ATE/ZIP <br />NUMBER/o/ / 0 � u <br />PHONE <br />EXPIRATION DA <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />5211—S: <br />INTENDED USE Poomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Uontact Name or Phone Number <br />TYPE OF WORKTJew Well E] Replacement Well E] Well Alteration/Modification ❑Other <br />/❑ Monitoring Well(s) # of wells E]Soil Boring(s) # of borings <br />El Geotechnical <br />F1 Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />New <br />■IS <br />Kalse vvell uasl <br /># of borings <br />Drilling Method,..�Wud Rotary ❑Air Rotary ❑Auger []CableTool 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 Th! kn s Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br />Grout Yment <br />l pt#— Neat Cement (94 Ib bag/5 10 gal water) and Cement �`1r sack mix/7 gal water <br />❑Bentonite (20% solids) ❑Other <br />Grout P Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By [-]Driller Wump Contractor ❑ Other <br />E] Concrete Pedestal mensions: Width ft Length ft Thick = in ❑Christy Box ❑Stove Pipe <br />PUMP ubmersible❑Turbine ❑Other HPC Pump Set / y(_1 ft Standing Water Levelt <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 />MINIR E NOTICE REQUIRED FOR INSPECTIONS - LEASE CALL (209) 953- ,697 <br />�qrSIGNED TITLE/[? r DATE l <br />T' <br />DEPART <br />---'ted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspecttiofj1 QY <br />COMMENTS &.u.IsrL, <br />T <br />1 <br />m <br />0 <br />0 <br />m <br />N <br />Dates <br />Aran � C _ E^ - C !D+'�j`'� <br />Date ❑ SPECIAL Well PermFi <br />Date a/ ❑ WAIVER Received <br />Date 1 ConstKucted Well Depth ft <br />'%'7 2 0/ — L."f4 , c .9Ae-i vl t ..moi , L.M /n. Q d7,44tA. — <br />PE Sc Received Check#/ Amount <br />Codes Info By Cash Remitted <br />Date <br />Permit/ Invoice # <br />Service Request # <br />Well ID# <br />X051 <br />t <br />-;)L i <br />o 2 'Q <br />$0g-�i, <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />st �l3lt?- <br />