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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 />NON-REFUNDABLE PERMIT /' CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM <br />%.DATE ISSUED <br />JOB ADDRESS 3-75 � `- I U <br />CITY/ZIP I ✓� C ! 1'> > <br />CROSS STREET P APN / jaT_7- 157;0 -3 q PARCEL SIZE t�LAND USE APPLICATION # <br />OWNER NAME Ce i 5 S c> tba-n d -e ft7 nye-s +i'�V► �� PHONE 6 35 <br />-/ —,Qr4 3 <br />'J 95_� <br />OWNER ADDRESS a � a .,r �l� U CITY/STATE/ZIP �/ +, nd�c a '7 <br />CONTRACTOR A S %ii l r; <br />PHONE ♦ Zz (� <br />CONTRACTOR ADDRESS lyq A The � �d CITY/STATE/ZIP IM6��r/ lG � ��7 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY <br />/ <br />;�S <br />l�TATE/ZIP <br />LICENSE C-57 ElC-61 ElD-09 E1 Other NUMBER t4oWi22Z EXPIRATION DATEII-730 r <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/PrivateIrrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public WaterSystem <br />If different from Owner: Water System Name (;ontact Name or Phone Number <br />TYPE OF WORK ew Well E]Replacement Well E]Well Alteration/Modification ❑Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />LJ rvew rump Lj rum me lacemeni Lj rum ne air L_j Kaise vveu uasm <br />WELL CONSTRU TION <br />Drilling Method .Mud Rotary ❑Air Rotary []Auger [:]CableTool []Push Point ❑ Other <br />Proposed Well Depth 00 ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size--- Ll <br />in diameter <br />❑ Conduct)�' or �Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched G1 Steel ❑Plastic ❑Stainless Steel ❑Other <br />G <br />Grout Seal DepthC) ft ❑ Neat Cement (94 lb bag/5-10 gal water) +Sand Cement /!S � 3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Metho umped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑Driller Xpump Contractor ❑ Other <br />E] Concrete Pedestal [J)i ensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level 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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697_ <br />SIGNED �f- TITLE 4 1 DATE 4 _/f _/ /1 <br />DE ARTMENT SSE ONLY <br />Application Accepted By mate <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />OMMENTS � Q ^ <br />Date <br />04ir-WiM=_ -Permit/ <br />EIRE <br />Asea Employee ID#zae <br />❑ SPECI L Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />I <br />EHD 43-06 8/01/16 (tt )IF,3 /„/ 00 WELL /PUMP PERMIT <br />T <br />1 <br />m <br />D <br />0 <br />0 <br />M <br />M <br />ur <br />