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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 <br />J�PERMIT GALL ZU9 953-7697 FOR INSPECTIONS 1� LXPIRL5 1 YEAR FROM UATE ISSUED <br />V <br />JOB ADDRESS t 2,C 411 a�� � �f /� CITY/ZIP M,,4A4e-Cq <br />CROSS STREET ` g ) �� APN r v Dv PARCEL SIZE Lu •LAND USE APPLICATION # <br />OWNER NAME VI V I If— LP -1—T / PHONE <br />OWNER ADDRESS ��Q d� S taFr 1�,C� . CITY/STATE/ZIP ^ '7 <br />CONTRACTOR , �rfi 61012-c � h ���� I � PHONE ^ �Ej / 1 r '_70 <br />CONTRACTOR ADDRESS qy ` X�l� hb�✓I �+I �~ �' CITY/STATE/ZIP 1-tAt I C A 1,1.'75211-0 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE V-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER btjq 06, -I EXPIRATION DATE C%S13il- 0LI <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring oil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells Vd Cil Boring(s) _5? # of borings []Geotechnical <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br /># of borings <br />❑ New Pump ❑ Pump Replacement ❑ Pum Re air ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method llud Rotary F1 Air Rotary 2Kuger ❑Cable Tool El Push Point ❑ Other <br />Proposed Well DepthIS 1 ��ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br />[_1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainle,s Steel ❑Other <br />I Grout Seal Depth ftat Cement (94 lb bag/5-10 gal water) L]Sand Cement sack mix17 gal water <br />F1Bentonite (20% solids) Other &—,) 4- Viten Y -4-e/ (S ",a"4r=4J 'jejn*14 S i1r ho�- <br />Grout Placement Method []Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller []Pump Contractor ❑ Other <br />E] 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 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 />M NIMUINL24 HOUR ADVANCE NOTICE REQUIRED FOR I/NSCP�ECTIONS- PLEASE CALL (209) 953-7697 <br />% <br />SIGNED i //y/` / TITLE ?�+i C� ea `a�j l,S� ) DATE <br />■■■11■■■■■■■■��■■■■■■IBJ■■■■■■■■■■■■■■■■■■■■■■ <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />■■!IJ■■■■■■■■■■��■■■■■IES■■■■■■■■■■■■■■■■■■■■■■ <br />■■■11■■■■■■■■�■■■Li■■IES■■■■■■■■■■■■■■■!�•!!�I�'�1'�!� <br />■MonsIIVi!'9W41W+ <br />■■ <br />■ ■ ■ ■ �����Illiril <br />' . <br />T <br />-f <br />m <br />D <br />v <br />v <br />X <br />m <br />DE ARTINENT SE O LY 7./�, <br />Application Accepted By c Date Area Employee ID# ~ <br />Grout Inspection By Date ❑ SPECIAL Well Permit 1� <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS A/ 1�11q r <br />Date _ `j / .i / /.X Constructed Well Depth <br />ft <br />PE SC Received heck <br />Codes Info By cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />