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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL T CALL(20%953-7697 <br /> 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM D E Is <br /> JOB ADDRESSIF1 a CITY21P rvn7��� � ump � m <br /> CROSS STREET / APN 3 ' • PARCEL SIZEgpyu,USE AP LIGATION# S <br /> OWNER NAME U G e W p I Ilt,f1r,��UNE 1 - zelly <br /> Ti- LO /� (�/ NPHNE <br /> �, rf6 7 fA <br /> OWNER ADDRESS � a Volc / CI S RT Z "�j 1— �(�1 <br /> CONTRACTOR G I/ `ter/•r v �(/ U /' �Ca \7�f��/ <br /> CONTRACTOR ADDR� r u.Y CITY T E/Z `75 J D ` <br /> �yM <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ,CIT (PT zip1� <br /> LICENSE C-57 C-61 D-09 Other NUMBER L EXPIRATION DATE <br /> DOMESTIC WELL r <br /> PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)F Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural -Industrial Water Quality Monitoring Soil Sampling/Characterization eee� <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> ap <br /> AY V� TYPE OF WORK New Well Replacement Well - Well Alteration/Modification Other 7! <br /> �,J Monitoring Well #of borings s) #of wells Soil Geotechnical If of borings <br /> W -Out-Of-Service Well Vut-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Re lacement Pum Re air Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point 1 Other <br /> a Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel 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 It Length ft Thick in - Christy Box 7 Stove Pipe <br /> Pu MP V Submersible Turbine Other HP 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 ALSb 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 UM 2 OU A VANCE NOTICE REQUIRED F(RIINSP1,E//1CTTIIONS-P�LJF SE CALL(209y�5 7697 4 <br /> SIGNED TITLE �' �l.G I ✓f DATE '-J Z V <br /> RE y4E�►T <br /> CF�V�D <br /> Ay <br /> 0 8 ?018 <br /> - -- Fes/po IN CpUN <br /> 41j-r/i pFpM���N 7Y <br /> A ME US O LY <br /> Application Accepted By Date Area EmployeeID# � <br /> Grout Inspection By Datelam, SPE AL Well Permit <br /> Pump Inspection By V Date �/ WAIVER Received <br /> Soil Boring Inspection By Date 0 Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permi <br /> Codes Info BU Invoice# Well ID# <br /> ash Remitted Service Re uest## <br /> n <br /> EHD 43-06 8/01/16 WELL/PUMPPERMIT <br />