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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 . (209) 468-3420 <br />NON-REFUNDABLE �P�ER�MIIT CALL 2I09 95c3-7�697 FOR INFSPECTIONS EXPIRES <br />XPPIRES 1 YEAR FROM <br />�OM DATEE IS <br />SUE <br />D <br />JOB ADDRESS Ii S 11rQ-b 4re zCITY/ZIP : -+n c-�+c, -, cA /✓�zr,,/ <br />APN UPPLICATION #CROSS STREETMC 1 �J LAND <br />OWNER NAME QPHONE Z63S^47LO <br />OWNER ADDRESS F—-C&}SloCy1vn,C '?t203 <br />CONTRACTOR /i�� Y� CLQ/ I PHONE Z � — i��j� •+ J L Z In <br />CONTRACTOR ADDRESS T/y�n 9 l i /` 1] r . l ✓'C'- y c A CITY/STATE/ZIPTracy CA / J F <br />SUBCONiRACTCR PHONE <br />1/. , <br />SUBCONTRACTOR ADDRESS r I ZIP W • S <br />LICENSE 2C-57 ❑ C-61 ❑ D-09 ❑ Other ✓NUMBER EtU-L3 6 EXPIRATION DATE O/c71 r 1 <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) a Dibromochloropropane (4392) a Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring KSoll Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE VF WORK ❑New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells Q(Soil Boring(s) _I # of borings X—Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 'KAuger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well De <br />p pttQ(�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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth !3 Oft Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other - <br />Grout Placement Method ❑ Pumped ❑ Free Fall ther ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By D 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 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 />WORKERACOMPENSATION LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />REQUIRED FOR INSPECTIONS - PLEASE CALL2 9) 953-7697 <br />TITLE_D r;11 P r 10 WnerO�� E`'r <br />N <br />O <br />A <br />DEPARTMENTUSEO LY �PECIAL <br />tt'�DateCv AreaEmployee ID#Dale ❑ ell Permit JI <br />Date F WAIVER Received <br />ate Constructed Vljfll Depth '3 v ft <br />EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />