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v� <br />WELL/PUMP PERMIT <br />III FUNTYEVVIRONMIINTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NITN-KEFUNDABLE PERMIT <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />(:ALL (LU9) <br />953-1691 FOR INSPECTIONS <br />tAPIKt5 1 YEAR FROM UATE ISSUED <br />JOB ADDPt SS f 5C>00 �2��huw��i <br />yS(11 <br />CITY/ZIP LO& <br />CA <br />e? -t5 Zye) <br />CROSS STREET +4P% tZ q <br />APN <br />CSO -001") PARCEL SIZE it LAND USE APPLICATION # <br />OWNER NAME 67 i`L� e-7 <br />,� n t <br />L + I <br />PHONE 200 <br />--5ZC-% <br />O ICJU <br />u ) <br />OWNER ADDRESS���� <br />r\ <br />CITY/STATE/ZIP <br />` <br />CONTRACTOR 11 3 M <br />Y <br />Ql <br />PHONE bZ% <br />CONTRACTOR ADDRESS la"151a441 <br />61"rt4n <br />CITY/STATE/ZIP J <br />A h eq sP1 '14j <br />"/`+>• 7-5-Z <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE VQ.0-57 El C-61 <br />0D-09 <br />❑Other <br />NUMBER I <br />EXPIRATION DATE <br />/} /� <br />9/-3/ A19 <br />DOMESTIC WELL SAMPLING: N]General Mineral/Coliform Bacteria (4391)tZDibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE KDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring []Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: a er ys em ame Contact Name or Phone Number <br />TYPE OF WORK CKNew Well ❑ Replacement Well ❑ Well Alteration/Modification E] Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings # of borings <br />❑Geotechnical <br />❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />Ll New rump L-irump Replacement LJrump Kepair LiKaise Well Uasin <br />WELL CONSTRUCTION <br />Drilling Method NMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth3!322 ft Excavation � in diameter ❑Open Bottom JAGravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched :rRZ 1-7 ❑Steel OPlastic El Stainless Steel ❑Other <br />Grout Seal Depth ;?gA? ft ❑ Neat Cement (94 Ib bag/5-10 gal water) Sand Cement le,"' • 3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Wumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length It Thick <br />❑Christy Box ❑Stove Pipe <br />PUMP JQSUbmersible❑Turbine ❑Other HP l!) Pump Set --j ft Standing Water Level %W It <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 />SIGNED <br />SS�- PLEASE CALL (209) 953-7697 <br />;/) DATE 7— Z / — /,, <br />DEPARTMENT USE ONLY <br />Application Accepted By 7/\ Date - d� <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COM ENTS NQ <br />S1. .I <br />Date <br />Area '/ �� C Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received _ <br />Constructed Well Depth <br />T <br />m <br />0 <br />0 <br />m <br />m <br />ur <br />PE C Received heck <br />Codes Info B <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />41G (, ITU - <br />3 "i <br />q <br />INS <br />yS(11 <br />70 <br />y3 t C, S I <br />lJ <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />