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• WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 466-3420 <br />NON-REFUNDABLE PERMIT CALL (209) PP3-7 697 FOR INSPECTIONS <br />NC VEXPIRES 1 YEAR F OM DATE ISSUED <br />JOB ADDRESS 0 CITY6P" (f,11V /L C4 U <br />CROSS STREET A/PN � — ` PARCEL SIZE AND USE APPLICATION # <br />% <br />OWNER NAME r' ` / v! l., v/' (//I �//r�7/,/r PHONE LA 7 <br />OWNER ADDRESS / VT U- /l_ ITV/STAT /LIP ' Co _/7 J'(`,0 r, <br />CONTRACTOR T {�pump PHONE 1 Z100-0 v 0 <br />CONTRACTOR ADDRESS 7�1y C CITY/STATE/ZIP `/q 0 ��/,/�C, ✓g) <br />SUBCONTRACTOR k I4 PHONE .Q 4 r <br />SUBCONTRACTOR ADDRESS <br />V I • l% I CCITY/STTATTEIZI/P_(� 2 r <br />LICENSE C-57 C-61 D-09 Other NUMBER Z LY (a 1VV EXPIRATION.DATE <br />DOMESTIC WELL PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392)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 Syste—Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Well Alteration/Modification Other <br />SoilBoring(s) #of borings Geotechnical <br />Out -Of -Service Well Renewal - Cross -Connection Repair <br /># of borings <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 Ib bag/5-10 gal water) 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 />Foncrete Pedestal Dimensions: Width ft Length It Thick - in i Christy Box - Stove PiDe <br />PUMP ✓ Submersible Turbine Other HP �_ Pump Set / b ft Standing Water Level r 1-7 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 TIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS CO_ NSATION LAWS. <br />M fl111M 24 HOUR ADVANCE NOTICE REQUIRED FOFQINnSP,EACTION/jS/- PLEASE CALL (209973-7 97 <br />SIGNED k l� .Y I TITLE ✓ ` C.P DATE W �91 <br />SATSIia■■■■■■■■■■■�■■■■■�11r■■■■■ <br />�'■■■■■■■■■■■■■■■■■■!moi■■■■■■■ <br />Application Accepted By <br />WTU <br />�i0Grout Inspection By a <br />.. - <br />Pump Inspection ByJw Soil Boring Inspection By <br />COMMENTS <br />E <br />Area Employee ID# <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well 4epth ft <br />T <br />m <br />D <br />M <br />m <br />N <br />N <br />G <br />n <br />i <br />IL f VE® <br />"' 6 2ol <br />TkHEAL <br />Rtqc,cs <br />EHD43-06 6/01/16 <br />WELL /PUMP PERMIT <br />I <br />11111111=31111111 <br />WMIM- <br />10 <br />EHD43-06 6/01/16 <br />WELL /PUMP PERMIT <br />