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' •l '� Ul i�r <br /> ` flu <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - T(20N3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 0 L i b. r•:ty CITY/ZIP G ct i I. I S6 3 2- m <br /> r '11 D <br /> CROSS STREET ' 1 d-�' R APN 1l J r ' `� PARCEL SIZE i�V LAND USE APPLICATION# A <br /> OWNER NAME �7 1 i�PHONE ( �j'�/� N <br /> OWNER ADDRESS �1 1 V V � 1`tA CITY/STATE/ZIP `v CA� . CIA 19-262- <br /> CONTRACTOR <br /> �"-2i 2- <br /> CONTRACTOR 4wv Dirl <br /> 1111 U. <br /> w A j�PHONE 101 y 922 -1111(/ <br /> CONTRACTOR ADDRESS �1 V CITY/STATE/ZIP m dyy �' . T?J-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /CITY/S]&TATE/ZIP <br /> U!f C c <br /> LICENSE TO111-1Li-57 C-61 D-09 Other NUMBER 4 t C� �� EXPIRATION DATE <br /> DOMESTIC WELL SA PILING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural f I Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If ifferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification [I Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Cl Pump Replacement I 1 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Too! ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation - <br /> 7-11 in diameter [I Open Bottom Gravel Pack/Gravel Size in diameter <br /> Ll Conductor_Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched 2-00 ❑ Steel lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /Ojo _ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 1-I 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 Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other 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. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED <. 1 TITLEID11.1 I`C'' DATE r ?_1 <br /> 1 <br /> r <br /> �AI J <br /> } i <br /> 1 0 <br /> F � <br /> i <br /> r fir£ R <br /> qAN J AQ iN C U TY <br /> I T1 <br /> DEPARTMENT USE ONLY 3r Gu <br /> Application Accepted By r Date tet-=y Area F� Emp!^yse! �• f'�,u <br /> Grout Inspection By _ _ nate rTU ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received ` <br /> Soil Boring Ins ect' n By Date Constructed Well Dedh ft <br /> C MME14TS <br /> 5^ <br /> PE SC *Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> 3�b 35 0cl > <br /> y� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />