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WELL/PUMP PERMIT P f <br />SAN JOAQUIN COUNTY ENVIRONM NTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT �7 CALL /J209 9.53- 697 FOR INSPECT S EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREE, I <br />//����nAP�tN� 2-L J� 5�)Z ARcEELrSRf __o wuu uSE APPLICATION # <br />OWNER NAME \ o/ ' "•�Vy-� r�V 1//rxh,,/ �•^ r^uN. �+ <br />OWNER ADDRESS .2 vlv,/ `yV���CJr6t �("k- VU <br />,IVB./(yl/l/J���L•�]( � _i� ` `�• 'I�( <br />CONTRACTOR `�+ V W LD U Cf ��c ` "" ` r S P u/rl b `� / )/1 / 1114 /1- 61�-Y-/I/�(OONNJE 1 V <br />CONTRACTOR ADDRESS " - CITY/ TATE/ IP ✓ t� `� -" <br />SUBCONTRACTOR ADDRESS' f I CITY/STA <br />nTE/ZIP I V <br />-61 <br />LICENSE C-57 C D-09 Other NUMBER2,1 (P (" 1X EXPIRATION DATE <br />DOMESTIC WEL <br />• PP PLINe: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) �-1 Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring i 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 Bodng(S) # of borings Geotechnical # of borings <br />Out-Of-Servicr V)iell Out -Of -Service Well Renewal - Cross -Connection Repair <br />New rump - rump 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 Schad Steel J Plastic Stainless Steel Other <br />Grout Seal Depth ft 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 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal _ Dimensions: Width ft Lent It Thick in J Christy Box J Stove Pipe <br />PUMP Submersible Turbine - Other HP Pump Set ft Standing Water Level It <br />1 HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />p -I <br />Of <br />D P RTMENT U E O IYY /rLJ'/_ <br />Application Accepted By Date Area Employee ID# A4 <br />Grout Inspection By Date r 1VSPEClk Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />�ttj <br />Permi <br />Service Request 4 <br />.. <br />EHD43-06 6/01/16 <br />WELL /PUMP PERMIT <br />