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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 <br />CALL (209) <br />953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IS UED <br />s1} <br />Z <br />JOB ADDRESS <br />60t (/t.l(ioj <br />CITY/ZIP G!�:LG /. <br />��%� <br />CROSS STREET <br />A P N <br />PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME�� o; f G� <br />� , <br />PPHONE46 2- y 331y <br />OWNER ADDRESS �l <br />l /4C C� C�� <br />CITY/STATE/ZIP J / (,(-k4/J <br />CONTRACTOR O'S -e' I I t C <br />,1't,(� �vkr <br />- PHONEZZ <br />Ila <br />CONTRACTOR ADDRESS 19� <br />i� <br />1�4 <br />CITY/STATE/ZIP �'l <br />(_ <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 ❑ C-61 <br />❑ D-09 ❑ Other <br />NUMBER 626 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) []Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑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 eW Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Borings) # of borings # of borings <br />❑Geotechnical <br />F1 Out -Cf -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pum Re air ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method X'Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth U 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 � in Thickness/Gauge/ASTM Sched 2-00❑Steel Lgrlastic ❑Stainless Steel ❑Other <br />Grout Seal DepthMo ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑Other <br />Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller XPump Contractor ❑ Other <br />F-1 Concrete Pedestal E])' ensions: 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 />M11�1MlJ�VI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED .�—CJS-� TITLE /x //% <br />)-I l / Q� DATE 9-e-/:7 <br />rn <br />1 <br />m <br />v <br />0 <br />m <br />m <br />Cn <br />rn <br />DE ARTMENT USE ONLY <br />Application Accepted y Date Area Employee ID#AR:k"L— <br />Grout Inspection By . Date ❑ PECIAL Well Permit <br />Pump Inspection By Date <br />Soil Boring Inspection By / �LDate <br />COMMENTS4 kA <br />,, <br />❑ WAIVER Received <br />Constructed Well Depth _ -�) 7 ft <br />PE SC Received Check#/ <br />Codes 1Afo B <br />Amount Permit/ <br />Dat seff vice Request # Invoice # Well ID# <br />e" a(CTU <br />�Ccashemitted <br />73 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />4r <br />