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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 CEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS N V � CIN/ZIP J +C ���� ( r ` / J 0 <br />CROSS STREET T t4 rRAA APN (1 J - F36 _I6 PARCEL SIZE LAND USE <br />--I�APPLICAATION# <br />OWNER NAME S S PHONE 'L02- Y66-337 66"33q <br />_{OWNER ADDRESS 33 LJ � CIT/STATTE/ZIP j4or �thn CA <br />CONTRACTOR PHONE f <br />) <br />- S-A <br />CONTRACTOR ADDRESS P V I L8, -Tr ac CITY/STATE/ZIP /� <br />SUBCONTRACTOR tA t p� C .,,C 1 C inet, -/ 7 Z - Dh <br />SUBCONTRACTOR ADDRESS 4lln �-/ri. el Li I•' •V CITY/STATE/ZIP ilSC LCA1 <br />(LICENSE 4 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER`nVJZ� O ExPIRATION DATE () I.?() I 1 j <br />DOMESTIC WELL SAMPLING: J General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) a Arsenic (4393) <br />INTENDED USE ❑ DOmestic/PrIvate ❑ Irrigation/Agricultural 7 Industrial 7 Water Quality Monitoring b,Soil Sampling/Characterization <br />7 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells 'WSoil Boring(s) I # of wring. ❑ Geotechnical 4 of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary Qquger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth Z S ft Excavation _�y in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />J Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth It A%leat Cement (94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall Other ❑ 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 />PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set ft Standing Water Level It <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 />M11=24 UR DVA?q E REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE -2i/ I / t'.0 DATE 1612 ylJ3 <br />DEPARTMENT USE, ON Y <br />7 Application Accepted Date <br />Grout Inspection By Date <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS Ajz*X &11 <br />Date <br />Date <br />Area- �SPECIAL <br />mployee ID#❑ Well Permit / <br />P WAIVER Received <br />Constructed <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />