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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 . (209) 468-3420 <br />JOB ADDRESS 0 11 11 — 1 W lit- Y 1 I I to ro <br />j #- t <br />CROSS STREET � `Y j^S APN 110,30 —O PARCEL <br />OWNER NAME , re �f a I—� <br />OWNER ADDRESS I ` <br />Ll q <br />CONTRACTOR%� 1 <br />CONTRACTOR ADDRES ✓ V <br />SUBCONTRACTOR 1 <br />SUBCONTRACTOR ADDRESS <br />L//C-61 <br />I1r._ , <br />LICENSE C-57 C-61 <br />D-09 Other <br />ONS EXPIRES 1 (AR FROM DATE ISSUED <br />CITY21P T/✓ 1 <br />SIZELAND USE APPLICATION # <br />PHOyE <br />/STATE P �/�[•�/� <br />P/H/19N�E C ct I <br />ICTAT0O ✓ W .l� V <br />EXPIRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloroorooane (4392) Arsenic (4393) <br />INTENDED USE omestic/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 />7- <br />N <br />m <br />0 <br />O <br />A <br />(n <br />TYPE <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) It of borings Geotechnical a of borings <br />Out -Of -Service 01 Out -Of -Service Well Renewal Cross -Connection Repair <br />VW <br />New Pum um Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <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 Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) _ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />J <br />Grout Placement Method Pumped Free Fall Other Retardant /.Accelerator (name( <br />I <br />PEDESTAL Installed By Driller Pump Contractor Other <br />+ <br />Concrete Pedestal Dimensions: Width It Le t 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 />(1 <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 24 HOUR AQVANCE NOTICE REQUIRED FO.R INSPECTIONS <br />y�-/PLEA,E CALL (209 --7697 <br />SIGNED TITLE ./� ( .C./ / 1 DATE 21 <br />� <br />AzY <br />-PAI <br />r 08 ?018 <br />NN CSU <br />Nry <br />lzp".T <br />PA TMENT USE O L ,�y'//�'A <br />Application Accepted By 0* 9-Ir—Date Area l%e � � Employee ID#/C LLL [ - <br />Grout Inspection By I IDate SPECT L Well Permit <br />Pump Inspection ByDate WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />ServiceRequest#r <br />%X0jI FP= W0104191A- WCi7A ffSj-[l_%"� �I <br />EHD43-06 8/01/16 <br />WELL )PUMP PERMIT <br />