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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 /> JOB ADDRESS 1 y L� Ta.s/7 1�/{ rS CITY/ZIP /w e�K C m -7 s� , m <br /> D <br /> CROSS STREET �Yctln�r APN PARCEL SIZE���LANDUSE APPLICATION# v <br /> OWNER NAME Y-gAtn P`lV'- Q11`��d J PHONE /D � m <br /> OWNER ADDRESS 21�� �(�(7 �1 r'S CITY/STATE/ZIP �'�',^^�q��1 //JA �[S -33-J <br /> CONTRACTOR {�QSP�1I�i_ l'1��ti �K�' PHONE <br /> t szz- I�2b <br /> CONTRACTOR ADDRESS 1 (YAP rS J"t CITY/STATE/ZIP d-P-3�b,, inn VIS-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS[:] F-1E] � 6LCITY/STATTE/^ t"/ZIIP I <br /> LICENSE )fC-57 C-61 D-09 Other NUMBER (D -7, EXPIRATION DATE -3 0-1 <br /> 1 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑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 Gontact Name or Phone Number <br /> TYPE OF WORK Xvew Well ❑Replacement Well [-]Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells [-]Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F-1 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 MethodXAud Rotary F1 Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth S 0 ft Excavation �_ in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> F-1ConductorCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter L�-' in Thickness/Gauge/ASTMSched 0 .-?_SO )�Z5teel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth5,PfS2 ft ❑Neat Cement(94 Ib bag/5-10 gal water) Sand Cement/0_3 sack mix17 gal water <br /> ❑Benton ite(20%solids) ❑Other <br /> Grout Placement Method-tgPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI"UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 } <br /> SIGNED ��--�— TITLE L r"o/-' DATE l(, S t/ / <br /> Q <br /> L <br /> DEYIPARTMENT USE )ONLY <br /> Application Accepted By Date Area Employee ID#A1!�,�./� <br /> W <br /> Grout Inspection By Date L Lot ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth Zza ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> -3 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />