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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />L:ALL ZO 953-7697'FI,OR INSPECTIONS t_APIKt5 7 Y AR FROM U[ATE ISSUED <br />JOB ADDRESS �/li V+�(T� N�- <br />: ', 1V <br />N '.J�r.�. r`" ✓y CITY/ZIP : T.J V` 7 <br />CROSS STREET W �'YW'IR- OG IN <br />NAME <br />OWNERADDRESS�44 p <br />PN <br />M" hr, <br />- <br />.- PARCEL SIZE1A1 Art- LAN <br />(�NrJ #CC n <br />-Zia <br />rVi-L PHONE <br />Lr&Q� CI /STATEILP ,I t <br />CONTRACTOR <br />< <br />N <br />+N �yv (��1 ^7 <br />PHONE `-t!" ` <br />CONTRACTOR ADDRESS ( <br />Cf64--7 <br />CITY/STATE/ZIPCA Nyy . <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE -57 C-61 <br />D-09 <br />- - Other <br />T /J <br />NUMBER 3Z0 y0 ` EXPIRATION DATE y 70 1 b <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391),- Dibromochloropropane (4392) -_i Arsenic (4393) <br />INTENDED USE �- Domestic/Private Irrigation/Agricultural -. Industrial 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 i -i Replacement Well ❑ Well Alteration/Modification Other <br />Monitoring Well(s) # of wells i7 Soil Borings) # of borings rpGeotechnical r u of borings <br />Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />New Pump Pump Replacement a Pump Repair -i Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method -i Mud Rotary Air Rotary C Auger yCable Tool Push Point ❑ Other <br />Proposed Welt Depth�'7*-14 ft Excavation in diameter , Open Bottom Gravel Pack/Gravel Size in diameter <br />(1�k <br />I Q 6 - Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched _jSteel - Plastic Stainless Steel - Other <br />Grout Seal Depth lS 7.O ft Neat Cement (94 Ib bag/5-10 gal water) _ Sand Cement sack mW7 gal water <br />Bentonite (20% solids) ther <br />Grout Placement Method I Pumped - Free Fall - Other -1 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller � Pump Contractor I Other <br />Concrete Pedestal _-Dimensions: Width It Length it Thick in Christy Box - Stove Pipe <br />au _-P - 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 />MINI UM j2 R ADVANCE NOTICE REQUIRED FOR INSPECTI NS - PLEASE CALL (209) 9p3-7997 <br />SIGNED <br />JI/I TITLE.��G� I�if7�ut sr DATE 3 Zi <br />Grout Inspection By Date oPECIAL well Permit <br />Pump Inspection By of 1 01 Date WAIVER Received <br />Soil Boring Inspection By Date Constructed WA[I Deptp ft <br />M ® r <br />'igii11'�F����L'�=37[���GIi .iL�'7iyl!Ti� <br />EHD43-06 8/01/16 WELL /PUMP PERMIT <br />✓? <br />