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'` , • 1. 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 INSPECTIONSEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /O�-%/C -/'CITY/ZIP � J5 <br />CROSS STREET CJ✓) <br />/ APNNJ/ 0 PARCEL SIZE !7� . nAND USE APPLICCATIONNj # <br />OWNER NAME sA 11 , A ff) <br />Q J <br />PHONE / 70 <br />OWNER ADDRESS 1^w Linff�,'°/ I CITY/STATE/ZIP Cz n7L <br />CONTRACTOR 1404a-( Y)D Pum P PHON 14?'f 11f <br />�y <br />e Q <br />CONTRACTOR ADDRESS ) hii (� CITY/STATE/ZIP/�I/�/1 {���G���yyyy�%J� C �l� ✓ C/�i <br />SUBCONTRACTOR /� PHONE /y/y <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE J� C-57 ❑ /JC -61 ❑D-09 Other NUMBER O / / EXPIRATION DATE J ✓ <br />DOMESTIC WELL SAMPLING: ($•General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) , <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Uontact Name or Phone Number <br />TYPE OF WORK 'New Well ❑Replacement Well ❑Well Alteration/Modification <br />E] Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal <br />❑Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair <br />❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point <br />❑ Other <br />Proposed Well Depth Z dv' ft Excavation Z(�5 in diameter [-]Open <br />BottomGravel Pack/Gravel Size �� in diameter <br />E] Conductor Casing in diameter / Conductor Casing Depth <br />ft <br />Well Casing Diamet �h Thickness/Gauge/ASTM Sched : , '/' ❑Steel <br />'Iastic ❑Stainless Steel ❑Other <br />Grout Seal Depft El Neat Cement (94 /b bag/5-10 gal water) <br />Sand Cement /✓ 2 sack mix/7 gal water <br />❑ B toni % solids) ❑ Other <br />I <br />Grout Placement MethodtfPumpgd ❑ Free Fall El Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller ump Contractor ❑ Other <br />E] Concrete P destal ime'nsions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HP J Pump SetX500 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 />SIGNED <br />MINIMUM -24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Grout Inspection By <br />Pump Inspection By <br />^.r.. � fes/• t �;,, �_ cin# <br />.p• <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS 5e -f-6 L-,alli12l� ��'G , . 1*,/ --- <br />T <br />1 <br />m <br />0 <br />0 <br />m <br />m <br />m <br />uLO) <br />.. ����•Service <br />Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />