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p L� -7 <br />• ` * WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL (ZUV) 9n, <br />53-/b9/ FOR INSPECTIONS tJ�CVIIKtb I YEEA��R'] <br />�FROOMl�DAATEE�ISSUED <br />11 <br />JOB ADDRESS 7 �� ��skq (2 CITY/ZIP p,!: / l�1 -/ /—.�C/L2 <br />CROSS STREET t + L� � APN i ` ` ot> J? PARCEL SIZE 0 LAND USE APPLICl!ATION # <br />OWNER NAME �- PHONEa)q <br />OWNER ADDRESS CITY/STATEIZIP <br />CONTRACTOR / PPjHjONNE/(�����J/�� <br />CONTRACTOR ADDRESS / CITY/STATE/ZIP04) 114 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CI ` /STATE/ZIP j <br />LICENSE C-57 El C-61 ❑D-09 El Other NUMBER EXPIRATION DATE /3l'/ <br />nnmFSTI . WFI I SAMPI wr- I—IGenPral Mineral/Cnlifnrm Rnrterin (4391)1—Inihmmochloronronane (4392) I—(Arsenic (43931 <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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />❑Out-Of-Servicell E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />F]New Pump Xpumo Replacement I-1 Pump Repair ❑ Raise Well Casinq <br />Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool F1 Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑Open Bottom F] Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <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 E] Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length 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 />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 />WORKEWCOMPENSATION LAWS. <br />MI IMUM J�4 H R�ADVfyA1yNNCE'/ OTICE REQUIRED FOR <br />INSPECTIONS - PLEASE CALL (209) 95 7697 <br />SIGNED //�' ,ItiiYJ /Y Y_-'N� TITLE 'JCJ(G! DATE �7� <br />DEPARTMENT USE ONLY <br />Application Accepted WV_ Date L <br />Grout Inspection By Date <br />Pump Inspection By ' Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area i2 Employee ID# <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />PE Sc Received Che Amount Date Permit] Invoice # Well ID# <br />Codes Info B Cash Remitted Service Request # <br />i 5 - Pe' <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />T <br />1 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />ur <br />