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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 4683420 <br />NUN-KEFUNDABLL rhKMIT^/ <br />L;ALL "!U9 953-7697 FOR INSPECTIONS <br />1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />7 „� . <br />' 1 <br />fl�r(` , jt. rl S-Yre e "i <br />Cm/LP <br />`EXPIRES <br />J"} r1 !f o <br />"CC ✓ it; 0 3 <br />CROSS STREET <br />,' / <br />rV L✓.So. <br />St APN 137-25C-253 <br />PARCEL SREy -,r LAND USE APPLICATION # <br />OWNER NAME <br />e�C a. <br />n <br />PHONE .2--I - i(,(, - &-y <br />OWNER ADDRESS <br />12- MG't'rG • 49- � U &, <br />7J <br />jc�/ <br />30D CRY/STATE21P <br />`-� L C V-4-0 n Crr / -7S Z15 - <br />CONTRACTOR <br />/1 <br />V h W I)i, <br />tl1CIL, <br />PHONE 20'1 36�) — (6ec-) <br />CONTRACTOR ADDRESS I I S 3 <br />11 r� <br />h1 w C k nw S T D •, .n <br />CRY/STATE2IP <br />/ <br />(3- k+ / 6 fi/ -7 S4, 3 Z <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CnTy/STATE/LP <br />PHONE <br />LICENSE D�C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER % 2-C O 1'-7 EXPIRATION DATE—L/ <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) L Dibromochloropropane (4392) 1_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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ MonitoringWell(s) #ofwells KSoilBoring(s) I #of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation 9 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 3 S ft K 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 ❑ Pumped ❑ Free Fall 5(Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width It Length It Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set It 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 />MI�11�4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED /� �S.G- TITLE Char :.l ft,- DATE i I -2y' -1-1 <br />ZAI <br />CZ/V't-.6 <br />e 9 2012 <br />QUIIy <br />Area Employee ID#A4;�" <br />❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date y s / Constructed Well Depth ft <br />COMMENTS <br />::f �e-•ter%//,��%r�.�i.�rc.���n��riii - ...�� <br />EHD 43-06 &01/16 WELL /PUMP PERMIT <br />