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WP <br />4 <br />WELL/PUMP PERMIT P ✓ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />IVUN-KEFUNDAB PERMIT I (;ALL (LU9) ySS-!tiy / FOR INSPECTIONS EXPII,/ <br />R S 1 YE FROM DATE ISSUED <br />JOB ADDRESSL z, Ir -Irl CITY?J ..i µ / T26 <br />CROSS STREET �/ n APN ��3LPARCEL SIZE LAND USE A PLICATION # <br />OWNER NAME i `r" • r- ',r j PHONE �/� I V Q— <br />OWNER ADDRESS ll `� l V' �(� e— CI TATE 'd • /t Z o /1 <br />CONTRACTOR V N "•� f•� 1/ r S �► vfLa-}�—P�1�,j-ONN/E �,Xt 3 w O [a <br />CONTRACTOR ADDRESS L CITY/STATE21 `� - ( ` 3 ! <br />SUBCONTRACTOR 1 PHA0 A <br />SUBCONTRACTOR ADDRESS • CITY/STAt► <br />/TE/ZIP ' - <br />LICENSE C-57 C-61 D-09 Other NUMBEAP I G EXPIRATION DATE <br />DOMESTIC WELLS PUNG: General Mineral/Coliform Bacteria (4391) - Dibromochloropropane (4392) r� Arsenic (4393) <br />INTENDED USE V 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 />Monitoring Wells # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out-'Of-Serv' a ell Out -Of -Service Well Renewal . Cross -Connection Repair <br />""'urn rum rte lacement rump Ke air Heise 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 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />rn <br />m <br />0 <br />O <br />A <br />fwa <br />s <br />e <br />S <br />V " <br />a <br />PEDESTAL Installed By Driller Pump Contractor Other r� J <br />oncrete Pedestal Dimensions: Width ft L th ft Thick in i i Christy Box P'pe y <br />PUMP V Submersible Turbine Other HP Pump Se ft Standing Water Level It <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN C ORDINANCES, STATE LA S, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURR AND CTIVE WIT T CALIFOR IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WO RS ENSATION WS , l <br />2 H R V N ' E I ED FOR SPECTIONS - PLEASE CALL (209) 95 - 6 7 l/,� `�J <br />SIGN TITLE I k r, pQ_ DATE <br />RE <br />MA <br />DEII <br />EP R T M E N T U N Y <br />Application Accepted By Date. l <br />Grout Inspection By Date <br />Pump Inspection By Date 0 <br />Soil Boring Inspection By Date <br />COMMENTS <br />�.............w� <br />■■■■■■■■■■■■s■■01 <br />■■■■■■■■■■■■NLYW, 2018 <br />■■■■■■■■■■■■!l�G;r1, . <br />■■■■■■■■■■■016 ►3. . <br />■■■■■■■■■■■■■■■•.44 <br />Depthllkeft <br />Area_ Employee ID# <br />PECIAL well Permit <br />WAIVER Received <br />Constructed Well <br />EHD 43-06 8/01116 WELL /PUMP PERMIT <br />