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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS A.- 1 FYPIRES 1 YFAR FRnlu nATF Iccl IFn <br />RECI <br />MAY 2 <br />E_N_VIRONMEI <br />DEP <br />10 <br />JOB ADDRESS V I W U r 1c/I /Z ✓V �j� CIS, � V nw� -G 3 <br />CROSSSTREET I- APN Igrb-o /LJ -t-0 PARCEL SIZE LAND USE A KATION# ]��(�'�j��j� <br />OWNER NAME O tit,! PHOT t/�E �� 3. `� / <br />OWNER ADDRESS v • �� +' CITY/STATE/ <br />�/� /t / yn r <br />CONTRACTOR ✓I' L � 1,1 VL l / ( �� /p�H(O�/�C7C, � /\/ <br />CONTRACTOR ADDRESS_A/1A <br />`1 / JU/.tt { / (/�. C to It Cl / ATE2 J L " 1S55`� <br />SUBCONTRACTOR A/ 1 / t ` —VT PHONE <br />SUBCONTRACTOR ADDRESS ITYISTATE21P <br />LICENSE C-57 C-61 D-09 -. OtherV1� NUMBER �O EXPIRATION DATE/2,11'E <br />l^ <br />, <br />DOMESTIC WELLS 2 <br />PILING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED 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 />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical # of borings <br />Out -Of -Service We Out -Of -Service Well Renewal Cross -Connection Repair <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 it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched 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 />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />oncrete Pedestal Dimensions: Width it Length it Thick in Z Christy Box - S VXV <br />ipe <br />PUMPV Submersible Turbine Other HP Pump Set 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 COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIF RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C PENSATION L <br />UM 24 H V E N ICE REQUIRED FOR I PECTIONS - PLE�A/SE CALL (209 <br />SIGNED ITL Idu W DATE <br />;-. -1 4,w I <br />AUNNTI I I I I I I av` <br />H <br />0)k. <br />19, <br />1^1 <br />.N <br />.N <br />C <br />i <br />RF Y4f,N% <br />,/IJc��VFD <br />0 y 2018 <br />F"N OR0 u/N co <br />ME <br />Application Accepted By P T Date USEONLY Area Employee ID# TND V/117),pMFN <br />- - D4Grout Inspection By Date 41 SPECIAL II Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth it <br />COMMENTS <br />EHD43-06 6/01116 <br />WELL /PUMP PERMIT <br />