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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 />JOBADDRESS 1 U v (P <br />V ' CT • A <br />K `ter <br />CITyrzky t„rUj2 ( r <br />O <br />CROSS STREET <br />APNZ44 <br />PARCEL SIZE WLAND USE APPLICATION # <br />G r i a <br />p lr <br />OWNER NAME <br />%` <br />/(�`//•1� <br />PHrE <br />(l <br />OWNER ADDRESS <br />•61 <br />CITY/STATE/ZIP <br />• <br />CONTRACTOR .,FLA <br />,,r <br />'/ "t <br />(�� t� <br />r �, L <br />Y�/1 2 G <br />(JLA <br />ADDRESS- <br />j`��• <br />• W U ` <br />/' <br />♦ Wt <br />" G <br />CONTRACTOR <br />' <br />SUBCONTRACTOR ' • <br />CITY/STATE/ZIP + ► <br />1 ��r� ////'''' <br />SUBCONTRACTOR ADDRESS � <br />PHONE <br />7 ] <br />CITY/STATE/ZIP <br />WO ILI 1 6 <br />LICENSE C-57 V-61 <br />D-09 Other <br />[,. / <br />NUMBE112� EXPIRATION DATE - <br />DOMESTIC WELL PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) - Arsenic (4393) <br />INTENDED USE tio 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 Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service W Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Replacement Pump Repair Raise Well Casing <br />Wci i Cnueronrnnu <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 It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic C Stainless Steel Other <br />Grout Seal Depth It - 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 Retardar4/ Accelerator name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Len [ it Thick it 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. 1 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 />MIN UM 24 H�O/iADV CE NOTICE REQUIRED FOP- INSPECTIONS -PLEASE CALL (209)g3-7697 <br />SIGNEDTITLE J#�)✓aYl DATE V I 12 <br />PP <br />uL�6N� <br />v <br />NNM�atjpn Accepted By <br />�oPQU <br />SpS. v\9p P�jMwcut Inspection By <br />.�HOEp Pump Inspection By <br />H Soil Boring Inspection By <br />COMMENTS <br />r <br />EHD43-06 8/01/16 <br />P: <br />9 <br />fl <br />MENT U�Y <br />Date 1 <br />Areamployee ID#�,��T��f!��7� <br />Date SPECIAL Well Permit <br />Date WAIVER Received <br />Date Constructed Well Depth It <br />W11floA - ' 1�C�il flT�►l I�.S�Pa <br />WELL/PUMP PERMIT <br />