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WELL/PUMP PERMIT <br />SAN JDAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NVN-KEFUNDABLE PERMIT t;ALL ZU9 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET_ <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />5 _F 44A Q CITY/ZIP _�`�%yv q C 9&C <br />Vc. � , APN j /�j Q' 6W(9'©1 PARCEL SIZE rs )Z?cL.AND USE APPLICATTION # <br />CCt <br />kl�cl <br />/ ' [ 614 C1 �Ch,• I PHONE Qg:pj— S(td,i ri S <br />CITY/STATE/ZIP LL' 'r:4 <br />:4��"7(�. -&!J50 <br />S.7 -/-d- <br />�G 7g7/�i ICV c���l LCi <br />—PHONE)k <br />CONTRACTOR ADDRESS SJ / N I nivc'. CITY/STATE/ZIP r e'Gdr%,. i Cul '670COL <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE JAIC-57 ❑ C-61 ❑ D-09 ❑ Other, <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 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 XSoil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name uomact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑Other <br />El Monitoring Well(s) # of wells E] Soil Boring(s) �:1 # of borings ,Geotechnical # of borings <br />El Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair n <br />E] New Pump El Pump Replacement El Pump Repair E] Raise Well Casing PAYxqr-,o <br />WELL CONSTRUCTION • \ECi.'`#V <br />Drilling Method )aMud Rotary ❑A[-]Cable❑El Rotary Auger [-]Cable Tool Push Point Other c VIED <br />Proposed Well Depth -7o ft Excavation 1 in diameter ❑Open Bottom El Gravel Pack/Gravel Size 14PI "n diameter <br />❑Conductor Casing _ in diameter / Condu::tor Casing Dept.1 tt Z018 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑E QU/ <br />Grout Seal Depth ft tgNeat Cement (94 /b bag/5-10 gal water) E] Sand Cement ��EgL7 pp� water <br />❑ Benton ite (20% solids) ❑Other �TMENT <br />Grout Placement Method ❑ Pumped ❑ Free Fall Other Tr rm• i ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump 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 />MINA M 24 HQWR.AQVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />DFPARTMENT USE ONLY /� l <br />Application Accepted By Date Area )) ) i, r t I'' Employee ID# ''`h ►1�i81/ <br />Grout Inspection By Date5­13 ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />+0 c, r c <br />Date (fZ i <br />V,11 W"30 <br />Constryycteq Well Depth <br />li' <br />Ln <br />i <br />m <br />D <br />0 <br />0 <br />X <br />m <br />w <br />PE SC Received h <br />Codes Info B Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />