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• .' WELL/PUMP PERMIT W;�r���- `l36 y/„� ��3° <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 'l CA�LL1 209 953-7697 FOR INSPECTIONS p� EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS U c P,i U e r' `C C� CITY/ZIP 1 Do. n /Q 0 i j,, m <br /> �/,, ��J n <br /> 1 CROSS STREET /�lr A r k APJJ N 2LI S-2'6 -25 PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME FT01H� Aw\G Pf" ���w7✓ PHONE �1 I� �� 7� conn <br /> OWNER ADDRESS ( B C�� R j.f- - VIA CITY/STATE/ZIP eN 1:5364, <br /> \ 1 <br /> CONTRACTOR �01 S e 1��S O r-!\l`\�� f ZYY+ PHONE Szz—j Cl Z9 <br /> CONTRACTOR ADDRESS 119 k Ile-s CITY/STATE/ZIP J�y��0,1eS4 G;P - r-1 , rr535 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / p <br /> LICENSE -ZC-57 [I C-61 F1 D-09 ❑Other NUMBER 6 t c�>✓Z2, EXPIRATION DATE <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: a er ys 19m a m e Uontact Name or Phone Number <br /> TYPE OF WORK ANew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells [-]Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <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 <br /> Drilling Method YMud Rotary []Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth IL/6 ft Excavation /Z- 11 in diameter ❑Open Bottom 'Gravel Pack/Gravel Size-�in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing eDh <br /> �� in Thickness/Gauge/ASTM Sched 2_00 ❑Steel Plastic El Stainless Steel ❑Other <br /> Grout Seal &(3 ft ElNeat Cement(94 lb bag/5-10 gal water) E]Sand Cement sack mix/7 gal water <br /> nite(20%solids) ❑Other <br /> Grout Placement Metho umpecl 94 <br /> ee all ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller KPump Contractor ❑ Other <br /> ❑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 /> MINIMUM X244 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769`7 <br /> SIGNED �e�' L,— TITLE �� 1` DATE -S ��G� � / <br /> O <br /> 0 <br /> IT— v� k <br /> Ic <br /> Q / <br /> qT .tfM <br /> Th F <br /> DE ARTMENTAU C ": LY <br /> Application Accepted Date Area daAEmployee ID4OUL-0 <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructe Well Depth ft <br /> COMMENTS <br /> PE Sc Received (_g-haGW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 037 33 <br /> F1S v <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />