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_ ✓t s <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUI14-MtruNUAt5Lt rERMIT <br />UA64- (1Uy <br />UbJ415U1 FOR INSPECTIONS <br />11 YEAR FROM DATE ISSUED <br />`��EjyXPIRES <br />3 <br />JOB ADDRESS <br />_ <br />CITY/ZIP N <br />• (, A.1 l4 !qI� a <br />CROSS STREET <br />APN �� I t) i PARCEL SIZES <br />LAND USE APPLICATION # <br />OWNER NAME <br />I <br />/ <br />G ^l a <br />i �� T i. <br />(D(� <br />PHONEaA— I `l' lI <br />OWNER ADDRESS <br />CITY/ <br />CONTRACTOR <br />yyPE1X <br />/ <br />QQ <br />PHONE J <br />CONTRACTOR ADDRESS L y� <br />L <br />Cy <br />CITY/STATE/ZIP <br />6 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />TY/STATE/ZIP <br />LICENSE C-57 11 C-61 <br />❑ D-09 I I Other <br />NUMBEREXPIRATION <br />DATE <br />DOMESTIC WELLS PLING: i General Mineral/Coliform Bacteria (4391) ! 1 Dibromochloropropane (4392) I Arsenic (4 3 <br />INTENDED USEomestic/Private u Irrigation/Agricultural # Industrial LiWater Quality Monitoring I Soil Sampling/C r I <br />IJ ublic Water System _ AECR/, „= r <br />If different from Owner: Water System Name Contact Name or Phone Number $�— <br />TYPE OF WORK ❑ New Well LI Replacement Well U Well Alteration/Modification 11 Other <br />11Monitoring Well(s) # of wells LI Soil Boring # of borings s) ❑ Geotechnica # of bo'rilygiu <br />❑ Out -Of -Service Well Out -Of -Service Well Renewal 11 Cross -Connection Repair EIM:COUiyn. <br />LJ,.. <br />u New t--ump a Fump t<e lacement 4 t-urnp rte air Ii rtalse vveii uaslng IN D RA <br />�� <br />WELL CONSTRUCTION <br />Drilling Method Vterin <br />LI Air Rotary Auger ❑ Cable T 1 ❑ Push Point D Other <br />Proposed Well ft Excavati n in dia ter I_I Open Bottom II Gravel Pack/GraveVze <br />in diameter <br />sing in dia eter / Conductor sing Depth ftWell Casing in Thickness/Gauge/ STM Sched I1 Steel ❑ Plastic L Stainless SteelGrout Seal ft ❑ Neat Cem nt (94 Ib bag/5-10 galater)11 Sand Ce nt ix/7 gal water <br />solids) L1 Other <br />Grout Placement Method ❑ Pumped LI Free Fall ❑ Other 11 Retardant / Accelerator (name) <br />PEDESTAL installed By Driller ❑ Contractor ❑ Oth <br />❑ Concrete Pedestal Ll Dimensions: Width ft Lengft Thick in Cl Christy Box ❑ Stove Pipe <br />CMP & Submersible#Turbine ❑ Other HP � U Pump Set It 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 />WORKERS COMPENSATION LAWS. <br />MINI U 24 HOU ADVANCE NOTICE REQUIRED FO(R��'�+rNSPECTIO S - PLEASE CALL (209) 953-7697 <br />SIGNED 7_ 2?)— TITLE l./" � DATE /— oZ�f-/ ly <br />DEPARTMENT USE ONLY <br />Application Accepted By Date r2 <br />Grout Inspection By N Date _ <br />Pump Inspection By { Date <br />Soil Boring�!�spection By i Date <br />COMMENTS `rL,Y" gall- ) A)(If, <br />T <br />-i <br />m <br />D <br />v <br />0 <br />m <br />m <br />y <br />N <br />Area J y 9 Employee ID# Ah A,,W <br />Ll SPECIAL Well Permit <br />❑ WAIVER Received <br />Cpnstructed Well Depth ft <br />PE SC Received he Amount Date Permit/ Invoice # Well ID# <br />Codes Info By_ Cas Remitted Service Re uest # <br />iqiya- D su 29 SIS <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />