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-Z- <br />WELL/PUMP <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />N%JN-r[thUNUAtlLt F-tKNII I <br />L;ALLL�� LUy =5-7[197 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />®� VGII CITY/Zip 'Tole -fly [ 4J✓0V <br />CROSS STREET_ I�7 <br />APN yVl �f 6 0 PARCEL SIZE - �� LAND USE APPLICATION # <br />OWNER NAME <br />� G/ PHONE <br />OWNER ADDRESS <br />CITYISTATE/ZIP <br />CONTRACTOR lG—/\r <br />_ 7/ -PHONE <br />C/ f44, <br />CONTRACTOR ADDRESS &yPI <br />41 ,4 r Fj CITY/STATE/ZIP <br />7)VfnY%I t)-/ <br />SUBCONTRACTOR <br />f i PPHONE C: �` / 7/ - I7av <br />SUBCONTRACTOR ADDRESS 1 <br />I ��" CI�TY}/STATEI7JP I[kV� l J7� ✓ �+ <br />LICENSE )(,C-57 ❑ C-61 <br />❑ D-09 ❑ Other NUMBER ✓" l Q EXPIRATION DATE 3V <br />DOMESTIC WELL SAMPLING: D General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural D Industrial D Water Quality Monitoring Soil Sampling/Characterization <br />❑ 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 D Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # cfborings Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump D Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary D Air Rotary 1( Auger D Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched D Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depthft ) Neat Cement (94 lb bag/5-10 gal water) D Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 'y. Pumped D Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP D Submersible❑ Turbine ❑ Other HP Pump Set it 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 VR <br />ADVANCE NOTICE REQUIRED FOR I SPECTIONS - PLEASE CALL (209)x953-7697 <br />SIGNED._ TITLE 3�Lii I DATE ✓ 1.1cf- ✓'?jjl <br />VARTMENT USE CyN Y <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By / Date > <br />Soil Boring Inspection By /�%L4 ( %Ji�> Date <br />COMMENTS <br />rn <br />D <br />0 <br />m <br />N <br />N <br />2018 <br />Areamployee ID#/� <br />❑ SPECIAL ell Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />-Permit, astService Requ!.36?��WOJJ�T"77M SAW LTOMPI MIN9 <br />EHD43-06 8181/16 WELL /PUMP PERMIT <br />