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h <br /> % WELL/PUMP PERMIT <br /> 9AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECMooTIONS EXPIRES 1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS C CITY/ZIP F m <br /> �a , <br /> CROSS STREET APN i d3 PARCEL SIZE AND USE APPLICATION# A <br /> OWNER NAME Ufl ?g- Actiodd m 4t DOBJ Q 0IJ •"-"'Ier PHONE o? <br /> OWNER ADDRESSa CITY/STATE/ZIP <br /> Q '32VCONTRACTOR PHONE l <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP ` q6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRAC R ADDRESS T /STATE/ZIP <br /> LICENSE 7 C-57 IJ C-61 ❑ D-09 ❑ Other NUMBERW& EXPIRATION DATE <br /> / 3)/V <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> hr <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L! New Well ❑ Replacement Well El Well Alteration/Modification ❑ Other <br /> r <br /> 11 Monitoring Well(s) #of wells 17 Soil Boring #of borings s) 11Geotechni a CEr �Q ings <br /> Out-Of-Service II 11 Out-Of-Service Well Renewal El Cross-Connection RepI �++ <br /> ❑ New Pump LX Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Wig <br /> Drilling Method ❑ Mud Rotary [I Air Rotary ❑ Auger 11 Cable Tool 11 Push Point 11 Other S ENJIAQUfN COU <br /> Proposed Well Depth ft Excavation in diameter 11 Open Bottom I-) GravelPacc/ 'Y~dv�VBR,�RT�.�._ in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic i Stainless Steel ❑ Other <br /> Grout Seal Depth ft I Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) !J Other <br /> Grout Placement Method I1 Pumped I I Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller i1 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal (]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP <br /> Submersible El Turbine I1 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CER IFY 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 /> WORKE COMPENSATION LAWS. <br /> TICE REQUIRED FO NS - PLEASE CALL (209 5 -7697 <br /> SIGNED TITLE DATE <br /> MDE ARTMENT SEo <br /> LYApplication Accepted By Date !n/LTL — Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By J Date o ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well De h ft <br /> COMMENTS 'JJ r e U L�l/ ,` <br /> PE Sc Received hec Amount ate Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />