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WELL/PUMP PERMIT G <br />r t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON -REFUND <br />REMIT, <br />C)ALL( 209 953-7697 FOR INSPECTIONS EXPI ES'YEAR ATE ISSUED <br />JOB ADDRESS <br />y/� <br />I i WWaLl <br />411 <br />�FyROM <br />CITY/ (5 (A aI 1 -3 —,7 <br />CROSS STREET <br />AP N <br />ARCEL SIZE AND USE APPLICATION # <br />IVI <br />OWNER NAME <br />Nt f z <br />PHO r <br />l 1'/40 <br />�J\ <br />c <br />OWNER ADDRESS <br />�1 • "• J'lit. <br />KI <br />CONTRACTOR e �,•{'G1� 1VA/ 1 tJ <br />CONTRACTOR ADDRE¢$!� 9 t "_ " I V' <br />/�J HONE J V v� <br />TY/ TXTE J %, <br />SUBCONTRACTOR <br />NJ <br />PHONE VJ19 <br />SUBCONTRACTOR ADDRESS1 <br />Y STATEIZIPArliq <br />LICENSE C-57 <br />C-61 D-09 Other r NUMBER XPIRATION DATE <br />DOMESTIC WELL PUNG: General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) _ Arsenic (4393) <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification - Other <br />MonitoringWell(s) #of wells SoilBoring(s) #ofbortngs Geotechnical xofborings <br />Out -Of -Service Vj 1 Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point - Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel ii Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped - Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Lent ft Thi in ChristyBox _ Stove Pi e <br />PUMP VIISubmersible 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 RDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND A IVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPE A N LAWS. <br />MINIM HOUR VANCE NOTICE REQUIRED FO'l�SP�-PLEASCALL (20 53-7697 <br />SIGNED TITLE �C�r <br />1 <br />I <br />EIVED <br />EPA TMENTU E O Y <br />Application Accepted By at <br />AreaoyeelD <br />Grout Inspection By Date <br />fAL<0� PECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD43-06 6/01/16 WELL/PUMPPERMIT <br />Mj� <br />EHD43-06 6/01/16 WELL/PUMPPERMIT <br />