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WELL/PUMP PERMIT <br />/VA 105006 P,/. <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE <br />JOB ADDRESS <br />UALL (-LUV) VOJ-/6Vl FOR INSPECTIONS <br />CITY/ZIP <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />"6r, �" , 9 52 <br />Fq;�t.�c, L V APN jOq ' �- 1 y 3 C' re <br />CROSS STREET PARCEL SIZE % LAND USE APPLICATION # <br />OWNER NAME 1 t nW a j1V LC:, � 'Fb�) �� P�`HO�NE <br />OWNER ADDRESS S�) I &WS-�bD CITY/STATE/ZIP S7 <br />J "�(l���J(.�r <br />CONTRACTOR e I V - i ( �rerra&4 )iW PHONE q ` <br />CONTRACTOR ADDRESS I �2 ,� ►� I t� j�r� y / CITY/STATE/ZIP S C"4 /q5 /Z- /(J <br />SUBCONTRACTOR✓�� PHONE <br />SUBCONTRACTOR ADDRESS <br />ff/ ' 1 <br />LICENSE KC -57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP !VIA n <br />NUMBER 1 o EXPIRATION DATE C/3 1 J/ "V I q <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) []Arsenic (4393) <br />INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring WSoil Sam piing/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPEOFWORK ❑New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings Geotechnical Z # of borings <br />F1 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 �/��'y�A e <br />Drilling Method P'Mud Rotary ❑Air Rotary Auger ❑Cable Tool E] Push Point ❑ Other A ��•ws / V <br />Proposed Well Depth iS - SO ft Excavation 6 in diameter E] Open Bottom E] Gravel Pack/Gravel Si AA4-2p�diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft 'SAIV <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Stei4nrltj <br />Njo /N VTC <br />Grout Seal Depth ft jKNeat Cement (94 Ib bag15-10 gal water) E] Sand Cement N_ticAQgal water <br />❑ Bentonite (20% solids) ❑ Other r�EN7. <br />Grout Placement Method XPumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑Concrete Pedestal EPimensions: 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 />MINIMU A 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIiyONS - PLEASE CALL (209)r95�3,--761977 <br />SIGNED [_ TITLE Lr1�117cel^ DATE <br />Grout Inspection By Date ❑ SPECIAL Well Permit J <br />Pump Inspection By ' Date Of ` ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received Chec Amount Date Permit/ Invoice # Well ID# <br />Codes Info B Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />r <br />1 <br />m <br />D <br />0 <br />o <br />m <br />m <br />er <br />ur <br />