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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 />r,,';JN-.JNPERMIT GALL 209 9533-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE 11 <br />JOB ADDRESS 93 110(%11 !C[ CITY/ZIP Fivl C-a1i� 9S i <br />CROSS STREET ���,� APN (� '; /� PARCEoLSSIIZE + LAND USE APPLLIICCAATIION # p <br />OWNER NAME / r'/b �lt7.t/�� J lO�, i� I ' / � PHONE—// <br />OWNER ADDRESS / ! _ ,� c © -ZeW I/TATE/ZIP <br />CONTRACTOR/%�/'_ _ PHONES/ <br />l� <br />CONTRACTOR ADDRESS /TJ1/ CITY/STATE/ZIP �•� <br />SUBCONTRACTOR A� {sem"IL L1� PHONE—� <br />SUBCONTRACTOR ADDRESS <br />LICENSE <br />❑ D-09 ❑ Other. <br />CITY/STATE/ZIP <br />NUMBER eCIp, ; z EXPIRATION <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USEomestic/Private ❑ Irrigation/Agricultural ❑ Industrial [:]Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name L;ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well Oeplacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring ell(,) # of wells E] Soil ASoil Boring(s) 'gNT <br />, <br />F-1 Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair RECEIVED <br />&d4ew Pump ❑Pump Replacement E] Pump Repair El Raise Well Casinq OR.. <br />WELL CONSTRUCTION dV L U l 2017 <br />Drilling Method &04ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other ""JOA <br />f ROhME <br />Proposed Well Depth_I Fj/') ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel 9QSrN c> Lin diameter <br />tNT <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -&1--- in Thickness/Gauge/ASTM Sched f:LZ E] Steel [Mastic E] Stainless Steel [_-]OtherGrout Seal Depth &r <br />ft ❑Neat Cement (94 Ib bag/5-10 gal water) /❑Sand Cement sack mix/7 gal water <br />'Adzentonite (20% solids) ❑Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By [:]Driller ump Contractor ❑ Other <br />❑ Concrete Pedestal Imensions: Width ==%= ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP &Submersible❑Turbine ❑Other HP ^/ l-2- Pump Set JLa`1J ft Standing Water Level 7§ = 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 />_ AA4 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76 7 <br />SIGNED L� jZ_ TITLE DATE !!�7 <br />=%1-7 LocLuArb-t- RD <br />t� <br />�j <br />�I V <br />—h a� <br />- L X30 <br />DEPARTMENT U E LY <br />r <br />IT- <br />7 1 <br />Application Accepted By Date Area Employee ID# -'0 <br />Grout Inspection By rL Date ' 7 PECIAL Well Permit <br />Pump Inspection By Date❑ WAIVER Received <br />Soil Boring Ins ection By <br />COMMENTS X IAr't i <br />Date <br />Well <br />ft <br />--i <br />m <br />D <br />0 <br />0 <br />m <br />m <br />CnN <br />PE SC ReceivedChe A unt Date <br />Codes Info B Cash Remitted <br />Permit/ Invoice # ell ID# <br />Service Request # <br />XO" -7 / ( <br />4 �! C <br />9 71 <br />CjCCU �w scu <br />EHD 43-06 8101/16 WELL /PUMP PERMIT <br />