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' WELL/PUMP PERMIT <br /> SAN�JAQUIN 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 <br /> S job ST1'i in�!ALA, �Z`� CITY/ZIP �C� (l ��/+��, �h Ir�J�Ly m <br /> LO <br /> D <br /> CROSS STREET LOR'C TT t'L APN ��,�I Z� Z � PARCEL SIZE LAND USE APPLICATION# f <br /> OWNER NAME ,��^}e V-, LAR LAO Y Q 1 PHONE 1 G�- Of ('�' N <br /> OWNER ADDRESS J L4 C�i� f��T'�t� 111't 4. ,� rZ-4, CITY/STATE/ZIP i�R <br /> CONTRACTOR M 0,S i I j Ir I <br /> DVA I )N'S C� �]P,H�OfNE -��/^2 L']� <br /> CONTRACTOR ADDRESS ! `Cie S Z'� CITY/STATE/ZIP P I lJ�-�'� 4c r �= �%SJ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI/TY/STATE/ZIP <br /> LICENSE [YC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 11 ' EXPIRATION DATE 1Y- 3 i - y <br /> DOMESTIC WELL SA LING: I I General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If afferent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK VNew Well ❑ Replacement 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 Mud Rotary CI Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ?- oD ft Excavation - 12,— in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth j ft <br /> Well Casing Diameter, iin., Thickness/Gauge/ASTM Sched 72,Q6 F1 Steel lastic LI Stainless Steel 11 Other <br /> Grout Seal DeDWjtt"e— ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite( Yo solids) I I Other <br /> Grout Placement Method fd'Pumped ❑ Free Fall Cl 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 r—y-��— TITLE D—Ilte, DATE -3 -I5�—�7J <br /> '1Q LU <br /> ti <br /> co _ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date_ 2 �Area `t!' Employee ID# K4"C6 <br /> Grout inspection By Date L I SPECIAL Well Permit <br /> Pump Inspection By Date I 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> C MMENTS r5 A-i1 <br /> i�l dG� X 27 r� r--�- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />