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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 I —EXPIRES (1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �` 100 K)OeW f111 O�1 CL <br />ITY/%JP ot) l �15 �I� <br />CROSSSTREET APIN / ..,� /--1�/ �,/ PARCELSIZE] AND USE APPLICATION# a <br />OWNER NAME SrS t7ilti-tJi4 ?1(7/M/�/IYVY ♦'/D �()nNPi83i > YZ6 1�5� <br />OWNER ADDRESS 1 "7 L % :: tJ{C I (•a W-1 a J t; t-* Ut.-�CITY/STATE/ZIP '-All'-All( 211-. , [ f'j-'1 '-'06 1 <br />py7 <br />CONTRACTOR t�L4N LNSL_:T14t-�S ♦ 11�C PHONE(91/(l)8852 -9)((& <br />CONTRACTOR ADDRESS <br />�r3� 160 GoLb U ��Y �IV� ��STaATOE(�ZIP Q <br />SUBCONTRACTOR -flIE 6 fZ- V PLL <br />1I %-J (Z. PHONE($&) 341 -�8/tZ 3C� <br />SUBCONTRACTOR ADDRESS CJ l6 C-1�V F -5-M (� �T�IC� C//m/STATE21P W- Sf�{��-/�N� t ,--4. f 5G <br />LICENSE V457 D C-61 D D-09 D Other NUMBER4tl l l t-� EXPIRATION DATEOZ Z! •�� Y <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring 2FSoil Sampling/Characterization <br />D Public Water System <br />N different from Owner water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well D Replacement Well 0 Well Alteration/Modification 0 Other <br />D MonitoringWell s) # of wells Boring(s) q to cf borings # of borings <br />( Soil Borin s G Geotechnical <br />D Out -Of -Service Well D Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pump D Pump Replacement ❑ Pump Repair D Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method D Mud Rotary D Air Rotary )( Auger D Cable Tool C Push Point D Other <br />Proposed Well Depth 2-5 ft Excavation in diameter 0 Open Bottom D Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness,/Gauge/ASTM Sched D Steel D Plastic D Stainless Steel D Other <br />Grout Seal DepthZ_ft XNeat Cement (94 lb bagi5-10 gal water) D Sand Cement sack mix17 gal water <br />D Bentonite (20% solids) 0 Other <br />Grout Placement Method D Pumped D Free Fall XOther M D Retardant / Accelerator (name) <br />PEDESTAL Installed ByIler D Pump Contractor -. Other <br />D Concrete Pe estal ❑Dimensions: Wicth ft Length ft Thick in 0 Christy Box Stove Pipe <br />PUMP D SubmersibieG Turbine D 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 />MIN U 2/4j/H�/OUR A NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED ' / /' - TITLE r- I -C DATE L (/ -2 z11 8 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />PA M ENT UAE O LY <br />Date Area —C Employee ID#_� <br />Date - ❑ SPECIAL Well Permit <br />Dale - ❑ WAIVER Received <br />�®Service Request # <br />EHD 43-06 "1/16 &K /7 --1 q -D 2 2 /3 (f? WELL /PUMP PERMIT <br />(Z <br />