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r , <br /> ' 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 ADDRESS Wy L(0 CITY/ZIP Z i✓c1-er7 r 47523b <br /> 3b m <br /> D <br /> CROSS STREETWArr'-V APN V PARCEL SIZER LAND USE APPLICATION# v <br /> // � [� <br /> M <br /> OWNER NAME j ( PHONE 6'j✓(1 .58 13 � <br /> OWNER ADDRESS 264 c) 9d CITY/STATE/ZIP � ? f ��� 9523 <br /> I�` <br /> CONTRACTOR CISH 11 0 C tr �kl �I C PHONE 1522'f�I 2,8 <br /> /1 <br /> CONTRACTOR ADDRESS I `1 /l CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP '' // / <br /> LICENSE X-57 El C-61 0D-09 El Other NUMBER �L7r 2Z EXPIRATION DATE Y'�� 6/ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)[]Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural E]Industrial ❑Water Quality Monitoring E]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 Replacement Well [-]Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <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)!rMud Rotary El Air Rotary ❑Auger []Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 00 ft Excavation in diameter ❑Open Bottom '[Gravel Pack/Gravel Size_in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter l 2_ in Thickness/Gauge/ASTM Sched 0,Z5(_> )<Steel ❑Plastic E:1 Stainless Steel ❑Other <br /> Grout Seal Depth r o ft [:]Neat Cement(94 lb bag/5-10 gal water) Sand Cement f ci 3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method[ <br /> umped ❑Free Fall E]Other E]Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Xpump Contractor ❑ Other <br /> ❑Concrete Pedestal❑)imensions: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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MgUMM 24 HOUR ADVANCE NOTICE REQUIRED <br /> FOR INSPECTIONS - PLEASE CALL (209)) 953-7697 <br /> � /-� -/SIGNED TITLE <br /> f <br /> DATE <br /> 41 <br /> Yny <br /> Q <br /> � N <br /> ti R M <br /> MIT-- <br /> D ARTMENT U E ONLY <br /> Application Accepted By Date Area rI no <br /> Grout Inspection By Date A SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS j ZZ vu A r --c I o <br /> PE SC Received hec Amount Date PermiU Invoice# Well ID# <br /> Codes Info B ashRemitted e u Service Rst# <br /> 33n,-r k1yVCUI':3U1111'1U <br /> ,.1 <br /> EHD 43-06 8/01/16 3t�.(/ WELL/PUMP PERMIT <br />