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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 �/ >/W CALL (2099) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />� % VMI / <br />JOB ADDRESS /P4 x?j / e2y /CITY/ZIP <br />CROSS STREET 5 � <br />Of'- D �Q APN J t7 —ls/ �%--2�ARCEL SIZE3ZI-ILAND USE <br />(APPLICATION <br />## <br />OWNER NAME ��//G�� Q/ PHONE < U`%' / <br />OWNER ADDRESS PC O/{(/J ?� �� / _� CITY/STATE/ZIP f rrw%a <br />CONTRACTOR ��i�G'� 6��/'c �/cf�'� PHONE✓j����� <br />CONTRACTOR ADDRESS �G CITY/STATE/ZIP �'/ Cid 2!5 <br />SUBCONTRACTOR //"/�/ S C/�T'j PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATTEE-//)ZIIP <br />LICENSE -57 -61 El D-09 [j Other NUMBER ��t7 0/.I�; EXPIRATION DATE11:57�1a C <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE [Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring []Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water bystem Name Contact ame or Phone Number <br />TYPE OF WORK ❑ New Well Akeplacement Well ❑ Well Alteration/Modification ❑Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring() ❑Geotechnical S # of borings # of borings <br />F1 Out -Of -Service Well []Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />Pum <br />F] Raise Well Casino <br />WELL CONSTRUCTION <br />Drilling Method >lud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth:3�,V ft Excavation L'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 T�kness/Gauge/ASTM Sched ��-ZL�? ❑Steel Vlastic ❑Stainless Steel ❑Other <br />Grout Seal Depth ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑- Sand Cement sack mix/7 gal water <br />Aentonite (20% solids) ❑Other <br />Grout Placement Method Jumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By +Driller El Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP submersible❑Turbine ❑Other HP Pump Set_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 />MIN/[H DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 954-76P7 <br />SIGNED TITLE DATE lI <br />E RTMENT U E NLY <br />Application Accepted By DateIF <br />u <br />Grout Inspection By M Date / <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />AreaEmployee ID#� <br />E]SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth '�,L)6 ft <br />i <br />T <br />m <br />D <br />0 <br />0 <br />X <br />m <br />N <br />N <br />M92= - niiiiiiii Permit/ <br />r4011" IVI <br />��I - �lr�l�iR/��IWAIMA�� <br />�,�rn�r or/ <br />On : �F"r-�rAMr fZjfAM <br />ice■ s: C*7MIV�/j�l •� <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />