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WELL/PUMP PERMIT <br />SAN JGAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELT(`1N AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE <br />'PERMIT <br />, / CALL <br />�(209) 953-7697 FOR INSPECTIONS / "EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS / 'V ;!"f/ �00167� S /!k CITY/ZIP `A*el -7-fZ / 7 - <br />CROSS <br />CROSS STREET /�-I"I��,r 4471 /Z/ APN 'C/� O �/ PARCEL SIZE "*S• YKAND USE APPLICATION # <br />o <br />OWNER NAME /v / / PHONE <br />OWNER ADDRESS Z Z G/ �/ 2 / CITY/STATE/ZIP 1--06 ' G7t 115~2 y7_ <br />CONTRACTOR t PHONE <br />CONTRACTOR ADDRESS '10 O 'l,t• 6� CITY/STATE/ZIP r' <br />SUBCONTRACTOR PHONE Z7 — 31to <br />SUBCONTRACTOR ADDRESS CIT/Y//STATE/ZIP G <br />LICENSE 4e_ C-57 CI C-61 F1 D-09 F1Other NUM R 7 S I Z3 EXPIRATION D TE /'0 �� o <br />DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Ba ria (4391) Dibro ochloropropane (4392) Arsen c (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural rI In ustrial ❑ Water ality Monitoring ❑ Soil Samplin /Characterization <br />❑ Public Water System <br />If different from Owner: Water System me Contact Name or Ph a Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Altera ion/Modification Other <br />❑ Monitoring Well(s) # of wells Ll Soil Boring(s # of b r gs I Geotech cal # of bor' gs <br />`❑/Ou1FOf Service Well CI Out-Of-Servic Well Renewal ❑ ss -Connection pair <br />]New ump ❑PumrReolaceme ❑ Pump Repair ❑ R i Well Casi <br />Drilling Method 11 Mud Rota ❑ Air Ro ry CI Auger Cable Tool ❑ ush Point ❑ Other <br />Proposed Well Depth ft xc vation in diameter CI Open Bottom Ll Gravel Pack/Gravel ¢e in diameter <br />❑ Conductor Ca ing n diameter / nductor Casing D th ft <br />Well Casing Diameter in Thickness uge/ASTM Sche teel ❑Plastic ❑ Stainles It/Eel Li Other <br />Grout Seal Depth ft ❑ Ne t Cement (94 lb b g/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ entonite (20% sol s) ❑ Oth r <br />Grout Placement Method ❑ Pumped Free Fall ❑ Other n Retardant / Accelera r (name) <br />PEDESTAL Installe y ❑ Driller I Pump ontractor ❑Other <br />[IConcre Pedestal I1 imensions: Width ft Length ft ThickX in CI Christy Box ❑ Stove Pipe <br />PUMP 6-5ubmersible Turbine 1.1 Other HP _Z_ Pump et 6 S ft Standing Water Level /-6 ft <br />I HEREBY CERTIFY THAT I HAVE PREP RED THIS PLIC ION AND THAT T WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCE STATE LAWS, AND SAND REGULATI S. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH TH CALIF RNIA CONTRACTORS STATE LI NSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />!0_7 <br />OUR ADV NC NOTICE REQUIRED F R IINSPECWNS - PLEASE CALL (209)7953-7697 <br />SIGNED TLE /Y.(j1r+LL� DATE ,7 — -7 / iK <br />D PARTMENT USEONLY <br />Application Accepted By / Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS Q�� ( c tl .— fl. l tl Jf�'/ <br />Area Z Employee ID#Pu <br />I SPECIAL Well Permit <br />I I WAIVER Received <br />Constructed Well Depth ft <br />I�a-If 03�/Z�l P <br />T <br />-1 <br />m <br />D <br />0 <br />0 <br />X <br />m <br />PE SC Received ec Amount D to Permit/ <br />o s Info Remitted Service Re uest # <br />Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />