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WELL/PUMP PERMIT <br /> n 1/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDAB "IT �-./ CALL 209 3-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE I <br /> ftrjjJOB ADDRESS I V4' CITY/LP in 12 ` <br /> L m <br /> f J CROSS STREET /, ((P��APN / ' I'PARCEL SIZE D 115E APPLICATION# <br /> -J NERNAME V` r� /�(5i I It If,-Z <br /> Qv e r- {�a )F �PHONEE a <br /> OWNER ADDRESS /�-y'�� ( CITY/STATE/ZIP <br /> C Z <br /> CONTRACTOR • /`�/ ' ��t ,PHONE G� J <br /> CONTRACTOR ADDRES V -1 4 1 I Y / CITY/STATE/ZIP t'//LCs S n <br /> �{�Vt ,//,fir \N <br /> SUBCONTRACTOR • / PHONE N <br /> �• `�^Joh (((��� SUBCONTRACTOR ADDRESS / CITY/STATE/ZIP r " i fi <br /> 1` , <br /> LICENSE C-57 V C-61 D-09 Other I NUMBER 2-7w o EXPIRATION DATE t <br /> 7 <br /> ` DOMESTIC WELLS PUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)F Arsenic(4393) � <br /> INTENDED USE v Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring . Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contac[Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> (� #u/bonnys #of borings <br /> Monitoring Well(s) #of wells Soil Boring(s) Geotechnical <br /> Out-Of-Service WellO}�"0-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Replacement VPum Re air 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 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 mix17 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> J PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimens' s:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine her fW nV 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 /> WORKERS COMPENSATION LAWS. 1i <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FWPECTIQNS-PLEMSE CALL(209)9��E <br /> SIGNED TITLE (. �yl J'J DATE <br /> N .,� <br /> O <br /> a 7 z C'7 <br /> PAYz o < <br /> REC -� <br /> JUN 1 <br /> SAN JOAQUIN COUNTY 1 = <br /> 1 P. MENT U E O LY <br /> ENTAL <br /> 75 ETFiRDEPP�t""PWceptedBy ate. Area Employee <br /> }SEAL Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> 1 PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> tL Codes Info ash Remitted S rvice Re e t <br /> S <br /> �l EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />