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411 <br /> WELL/PUMP PERMIT IU <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABL ERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ion 19 C�JOB ADDRESS CITY/ZIP m <br /> !' `f D <br /> CROSS STREET APN��� /� r V PARCEL SIZE LAND USE APPLICATION# A <br /> t, m <br /> OWNER NAME Ti Lip S /7 PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> AA k <br /> CONTRACTOR -7-120 <br /> // 1 ///���mflwMl��_ <br /> PHONE 2 <br /> CONTRACTOR ADDRESS, !i l 0 CITY/STATE/ZIP �]� ✓Z <br /> SUBCONTRACTOR J PHONE ���or <br /> SUBCONTRACTOR ADDRESS CI Y/STATE/ZIP q.�/^/(J'J` <br /> LICENSE C-57 -61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 13) I 1 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) 1 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ?,:Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Ikew Well i eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> )<Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )R Mud Rotary ❑ Air Rotary ❑ Auger (I Cable Tool J Push Point 11 Other <br /> Proposed Well Depth�ft Excavation 16+ in diameter LI Open Bottom p<Gravel Pack/Gravel Size_in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched c,6.1 a0. l Steel X'Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 15-0 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ?LSand Cement U•3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method V Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By CI Driller X,Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width_3 ft Length ft Thick in ❑ Christy Box 11 Stove Pipe <br /> PUMP I�jSubmersible l Turbine ❑ Other HP Pump Set 1 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 WS. <br /> IMU H ADVANCE NOTICE REQUIRED F S T S -P E E CALL (209) 95A-7697 <br /> SIGNED TITLE DATE <br /> Q <br /> D. <br /> F <br /> EP RTMENT U E NLY <br /> Application Accepted By r a Date Area Employee ID# Iv9 <br /> Grout inspectiun By Date 'L I I SPECIAL Well Permit / <br /> Pump Inspection By _. Date _ I I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Codes fo ash emitted Date Service Request# Invoice# Well ID# <br /> z3 <br /> ZZ <br /> W 03-3317 <br /> 45 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />