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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDA13L^,Er PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM /DATE ISSUED <br />JOB ADDRESS a Dot <br />11}. I r� j Vc 7 CRY/ZIP c 4e) ( t -A1, •n ., CA <br />CROSS STREET - ✓ ` r APN / J 3 -1 -3 C'i ARCEL SIZE //`� LAND USE APPLICATION # <br />OWNER NAME C1 a UY, 7ya , 4Us Tr 64-af PHONE <br />OWNER ADDRESS r <br />.O1 �J�Q'/� \ <br />r, 7 o G • CITY%/STATE/Zip � 1� ��- <br />2s269 <br />CONTRACTOR <br />I t'�1y G <br />�j <br />er�� E�r..l,n �Yc�,> // j ti (l I �� PHONE �Oq <br />, Q�jA <br />CONTRACTOR ADDRESS <br />/l15 <br />1-•� x.1�3 <br />CITY/STATE/ZIP Ir <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />/J CITY/STATEIZIP <br />►� <br />LICENSE 1Y_C-57 <br />❑ C-61 ❑ D-09 <br />❑ Other NUMBER 1:74�> EXPIRATION DATE <br />6 Po <br />DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) a Dibromochloropropane (4392) a Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring XSoil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ,ID_Soil Boring(s) _ I # of borings JYCeotechnical # of borings <br />❑ Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casino <br />Drilling Method ❑ Mud Rotary, ❑ Air Rotary ){Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth -7_c ft Excavation 7A_ in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/GaugelASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth2-5- ft .ACNeat 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 jWther TRetardant I Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length tt Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine D Other HP Pump Set ft Standing Water Level fl <br />1 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 />MINIM <br />SIGNED <br />Application Accepted Bj <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring <br />COMMENTS_ <br />REQUIRED FOR I SPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE k' i dew- DATE A0 - Z- <br />TMENT USE ONIL <br />mate - +++7777 Area ` / ✓ 1 1v Employee ID# <br />Date.}-- ❑�SP�� EC -IAL Well Permit <br />Date / 1 ❑ WAIVER Received [ <br />abate-- I '�Construged Depth ZJ ft <br />EHD43.06 6/01/16 WELL/PUMP PERMIT <br />