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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 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESSe.'1 �JLJ Fl1l'.V`.tn)Ley ?� Cr.Y/LP J�_I�1Ov'\ � ZOW' <br />CROSS STREET WD • I..Gt 11.,(� �[� , APN I J v' V L PARCEL SIZE(Q <br />' ' ` LAND USE APPLICATION # <br />OWNER NAME Pete 1• `N(,'�.1G� LLC- LlPHONtEy ]� (�f��,n/,, <br />OWNER ADDRESS 77 V\\� • IiA1 lw X1Vllw 0,1 L( CITYISTATE/ZIP J`IQx,.Tr_l `ay-\ l.�l-](7LV{(! <br />CONTRACTOR '7W 1 1 � Y iY' {y.(,. PHONE 2A , - {G•/t - -noo <br />CONTRACTOR ADDRESS 1 J� L(J.(,.� �04L.7 f )t D(, r� CITY/STATE/ZIP G � CA 1 9 � C 3 2— <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE C-57 n C-61 17 D-09 n Other NUMBER O ? EXPIRATION DATE q — 3(0 �I(J <br />DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391) Fl Dibromochloropropane (4392) F1 Arsenic (4393) <br />INTENDED USE n DomestictPrivate n Irrigation/Agricultural n Industrial n Water Quality Monitoring (Soil Sampling/Characterization <br />F1 Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK n New Well n Replacement Well F Well Alteration/Modification ❑ Other <br />F1 Monitoring Well(s) #of wells )(Soil Boring(s) I #of borings n Geotechnical #of borings <br />F1 Out -Of -Service Well F, Out -Of -Service Well Renewal n Cross -Connection Repair <br />n New Pump ❑ Pump Replacement n Pump Repair n Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method n Mud Rotary n Air Rotary n Auger n Cable Tool -1 Push Point n Other <br />Proposed Well Depth6b It Excavation -G I I in diameter n Open Bottom n Gravel Pack/Gravel Size in diameter <br />n Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel n Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) n Sand Cement sack mix17 gal water <br />F1 Bentonite (20% solids) n Other <br />Grout Placement Method n Pumped ❑ Free Fall ❑ Other n Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller ❑ Pump Contractor n Other <br />n Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box n Stove Pipe <br />PUMP n Submersible n Turbine n Other HP Pump Set ft Standing Water Level ft <br />1 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 W�jI�ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPEN3*4(N LAWS. <br />SIGNED <br />Application Accepted By <br />Grout Inspection By <br />NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-72269{70C <br />TITLE J-Y�.-CF F—I %n r r DATE 4 13/ <br />l l b <br />fA <br />g <br />t <br />R q)'4fAN <br />�c��VFO <br />►OR ° 4jo <br />?41 <br />w1RONMC oUNB <br />OFp NT,q� rY <br />'gRTM�NT <br />M E N T U;SPON.jDateAreEmployee iNkmo <br />Date Fl SPECIAL Well Permit <br />Pump Inspection By Date Fl WAIVER Received <br />Soil Boring Inspection By �%f� �K Date Zd/% Constructed Well Depth <br />COMMENTS <br />EHD43-06 8/01/16 WELL/PUMP PERMIT <br />