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WELL/PUMP PERMIT <br /> SAN4J,nAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS b�-i 5'2— 1Aev%rVi J CITY/ZIP 4 574 yen m <br /> D <br /> CROSS STREET W�? �r C-C- APN �ZZf I J ry r PARCEL SIZE LAND USE APPLICATION# A <br /> _1 r/�- —r r Cn <br /> �+ <br /> OWNER NAME y%'A/rrI ry Nelson / y�-e 0 ( "A V41 f PJ PHONE (0i 1 � <br /> OWNERADDRESS 1 6i�IYL 14 e,rV p-d CITY/STATE/ZIP <br /> `T <br /> CONTRACTOR MOLNeWl'i bf-jlIlh l Tyr" PHONE SL2 <br /> 2- 195 <br /> CONTRACTOR ADDRESS I I 1 A I b e rS A CITY/STATE/ZIP/r I(1 U1-r jib; I S 3 5 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE//ZIP (� Q <br /> LICENSE *-57 [1C-61 [ID-09 ❑Other NUMBER{//p b&7,f - EXPIRATION DATE T-36 1 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial E]Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> lip <br /> TYPE OF WORK +I eplacement Well ❑Well Alteration/Modification ❑Other <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) ❑Geotechnical #of borings <br /> E]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>'Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 246 ft Excavation in diameter ❑Open Bottom E]Gravel Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. in Thickness/Gauge/ASTM Sched '2-0(--) ❑Steel 'KPlastic El Stainless Steel ❑Other <br /> Grout Seal Depth I ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> -'16Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Free Fall ❑Other E]Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> E]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 /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED r.-�� TITLE Oyy�>P r ' DATE `l r <br /> S <br /> O <br /> 1" <br /> N / C <br /> T <br /> kK <br /> Tt <br /> L <br /> EPARTMENT USENLY + }'J <br /> Application Accepted By Date Area l Employee ID# � �=+��-V <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspecion By Date Constructed Well Depth ft <br /> COMMENTS YESITEP <br /> - <br /> PE SC Received Che Amount Permit/ <br /> ode I o B ash emitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />