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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 /> 28 90 ky pj s�a���. 9- jj m <br /> F <br /> JOB ADDRESS � 'e I' CITY/ZIP m <br /> ,a D <br /> CROSS STREET <br /> '54e I N PLG�(/t1A� /`"' APN PARCEL SIZE t6'f� LAND USE APPLICATION# a/ <br /> OWNER NAME C(Ae- IQd PHONE fon ( Zri,{� vi <br /> OWNER ADDRESS �ZS� 1 L)2 IC-L POfJ T CITY/STATE/ZIP jSCQtoh cq 320 <br /> CONTRACTOR IM t�f I k S '( ( l l INk C- PHONE 5 2-2-- Z� <br /> CONTRACTOR ADDRESS l A CITY/STATE/ZIP/"'d "'d ( ' <br /> �G, , C ?. -7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT//Y/STATE/ZIP ' <br /> LICENSE -57 ❑ ❑ ❑ // <br /> C-61 D-09 <br /> Other NUMBER (pt�J(z,2,7- cl <br /> EXPIRATION DATE -/7 /�-/�/ <br /> DOMESTIC WELL SAMPLING:DgGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricult-ural ❑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 VNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells [:]Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement [:]Pump Repair [-]Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool []Push Point ❑ Other <br /> Proposed Well Depth 210 Excavation 1 Zi in diameter L)Open Bottom X Gravel Pack/Gravel Size in diameter <br /> ❑Conductpr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Jl7 in Thickness/Gauge/ASTM Sched 7_00 ❑Steel �8plastic E)Stainless Steel ❑Other <br /> Grout Seal Depth ZOO ft ❑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 NRumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By E]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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE /�/^'1 ��'� DATE <br /> w <br /> 2 � <br /> �v c <br /> i <br /> 1 <br /> JCR <br /> R <br /> P T <br /> � DEPARTMENT USE ONLY <br /> plication Accepted By % ✓r Date_6 2 -� Area C/ �� Employee ID# <br /> r � �I h <br /> Grout Inspection By Ailt,fCk,— Date M /� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received L� <br /> �� <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ;-S ain :�- <br /> I <br /> PE Sc Received Check#/ Amount Per i " Well ID# <br /> Codes Info B Remitted Dat Service Request# nvolce <br /> q, I I ys <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />