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A <br />n / l <br />WELL/PUMP PERMIT f1 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STCCKTON CA 95205 - (209) 468.3420 <br />I4L)N-MtI-UNUAHLt r ttnnl l C 4.ALL U HbJ-/6y/ FOR INSPECTIONS txF IKhb 1,, �Y/�EAR FROM <br />'VA/YT�E ISSUED <br />JOB ADDRESS ✓ U i v C./Z"�L 1`'(� / 1 l J Z/ C/ <br />CROSS STREET L �i��r A�� APN13 9 O PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME % I` �/ �Vc• LP PHONE <br />OWNER ADDRESS ( V ( ✓ iWTATEIZIP %meq �GJ Q !C=1 —Lc <br />CONTRACTOR 1 �-�J/'n� • /1t �ej //I` �] `r r PHONE w r / ,QV /j ` ��,y! <br />CONTRACTOR ADDRESS 7Wl L1 rV�7 - r/V �� RJ. Suite, 100 CITY/STATOZIP J G k n/ ( q..V Z4 <br />SUBCONTRACTOR Faber 01-014% PHONE qjv 37I- L j <br />SUBCONTRACTOR ADDRESS ;3(n i71 '"A' -d -'CITQYISTAAT�EIZIPSK(/�W�`LII �O Cr/ 156 /I <br />LICENSE t C-57 LI C-61 G D-09 D Other NUMBER I FQ`' -7 EXPIRATION DATEO21 Lq' uzo <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) 0 Dibromachloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE n Domestic/Private n Irrigation/Agdcultural O Industrial D Water Quality Monitoring %yi Soil Sampling/Characterization <br />D Public Water System <br />If different hem owner: WMor System Nemo Contact Name or Phone Number <br />TYPE OF WORK D Naw Well D Replacement Well n Well Alteration/Modifiralion U Other <br />U Monitoring Well(s) # of wells n Soil Baring(s) o of boring' 4./Geotechnical n of borings <br />O Out -Of -Service Well U Out -Of -Service Well Renewal n Cross -Connection Repair <br />U New Pump U PUMP Replacement D Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method U Mud RottaryU Air Rotary ,Auger U Cable Tool n Push Point n Other <br />g7,A`���l!11 <br />Proposed Well Depth�it Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />U Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ In Thickness/Gauge/ASTM Schad ❑ Steel 11 Plastic n Stainless Steel n Ogler <br />Grout Seal Depth it Neal Cement (94 lb bag/5-10 gal water) n Sand Cement sack mixR gal water <br />❑ Bentonite (20% solids) D Other <br />Grout Placement Method r Pumped n Free Fall D Other ❑ Retardant / Accelerator (name) <br />PEDESTAL installed By CI Driller [I Pump Contractor n Other <br />Concrete Pedestal DDimensions: Width R Length ft Thick in D Christy Box n Stove Pipe <br />PUMP U Submersible❑ Turbine U Other HP Pump Sel it 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 />79F <br />OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE VP / Exploartion Coordinator DATE 05.01.2018 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By. <br />MENTUS N Y <br />Date __Area_l Employee ID#, <br />Date ❑ SPECIAL Well Permit <br />Date 0 WAIVER Received <br />Date tr Constnrpted Well Depth _ ft <br />Y�etv? <br />lr 01 Z018 <br />AQUIN C <br />EpgRTT, N <br />MFNT <br />EHD 41-08 raNsed 4/14/18 WELL /PUMP PERMIT <br />