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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-REFUKDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> C Ln <br /> JOB ADDRESS �� J �GCITY/ZIP �I� 5 �' W m <br /> �• 1 { J I�1��J i ' iI' Q (� <br /> CROSS STREET nI t '� A PW APN W y I I V I I PARCEL SIZE v �1�LAND USE APPLICATION# <br /> r f 7 i�V m <br /> OWNER NAME v I I V PHONE �V 1 I� <br /> OWNER ADDRESS C V 1 CITY/STATE/ZIPLrt <br /> W —� 0. 0 <br /> CONTRACTOR I S np"II1'�L ./ (,/ PH/ONE 200 [L-2 I 20 <br /> CONTRACTOR ADDRESS Iy V CITY/STATE/ZIP (podj �L( J /r � 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �CIIT1YI/ISTATyE//ZIP, �1 + <br /> LICENSE �<-57 Ll C-61 F]D-09 [I Other NUMBER EXPIRATION DATE_V-1 <br /> DOMESTIC WELL SAMPLING:4General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Q'Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characteri <br /> F1 Public Water System `'�� <br /> If different from Owner Water System Name Gontact Name or Phone Number 3 L,l a <br /> TYPE OF WORK [*New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ',: E3 <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑ *of or gGeotechnical {� <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair Nj AQUiTJCO�OPdyUaTy <br /> El New Pum El Pum Replacement El Pum Repair E]Raise Well Casing <br /> WELL CONSTRU TION PARi- E"-NT <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ]Gravel Pack/Gravel Size—L _in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched El Steel Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth < 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 Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> El Concrete Pedestal E])i 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR I SPEC IONS - PLEASE CALL (209) 953-7697 4 <br /> SIGNED /���!� e TITLE_ �1' DATE <br /> i <br /> r <br /> c <br /> EPARTMENT /USE <br /> 1 ONLY <br /> Application Accepted By I"�" l� / Date [Q' 3/'/ Area ('r V/ Employee ID# (►�' c� <br /> Grout Inspection By °, Date / 1 l } ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By tD/ate C Constructed Well Depth ft <br /> COMMENTS -rri.t nJ G(,'d V y ✓'1 oZ Cr `1 �- G W,.t re:if/ r 'C 1 i <br /> PC f M1 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BYl sh Remitted Service Request# <br /> D-- <br /> EHD 43-06 8/01/16 S l �� I WELL/PUMP PERMIT <br />