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WELUPUMP PERMIT Y� i <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABL ERMIT LL (22079) 9y5�33-7697 FOR <br />JOB ADDRESS 3 J `/7-2 I r✓ r �%f�� w <br />CROSS STREET ✓A k V _ APN �/�� _Z w —Z <br />OWNER NAME G r- VlaW <br />OWNER ADDRES�S-f� 0 0 0 5 d <br />CONTRACTOR / <br />CONTRACTOR ADDRESS v W ✓G <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS IV <br />LICENSE C-57 C-61 D-09 Other <br />)INSEAWPYDATE ISSUED <br />CITY21P I IM (' 6 <br />ildi ". AND USEAPPLICATION # <br />fI/ <br />PHONE CI a C) <br />STATE I <br />C6 ✓ V <br />7 0, 1 l'7 n <br />CITY/STATE/ZIP V Y <br />NUMBEa� EXPIRATION <br />DOMESTIC WELLSPLING: 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 System Name Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well - Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Borings) # of borings Geotechnical # of borings <br />Out -Of -Service WV Out -Of -Service Well Renewal Cross -Connection Repair <br />m <br />0 <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 Sched Steel Plastic Stainless Steel ' Other <br />I <br />Grout Seal Depth ft Neat Cement (94 lb 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 />Concrete Pedestal Dimensions: Width ft Lent ft Thick in Christy Box j Stove Pipe <br />PUMP V - Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY R INANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND AC V TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />[1 <br />WORKERS COMNLAWS. <br />v J <br />MINIM HOUR AD CE NOTICE REQUIRED F R INSPECTIONS - P/L�E'A/7AE CALL (20 -7697 <br />SIGNED TIT VVZM(tet/ V V DATE <br />VG 1I,3II I Ir,0\-`.� <br />AQP QpplieolMRccepted By <br />E �G' Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />IOrE NJ Y <br />Dlate Area EmployeeID#� <br />Date SPECIAL Well Permit <br />Date Q WAIVER Received <br />Date Constructed Well Depth ft <br />VVIP11 � <br />r <br />EHD43-06 6/01/16 WELL/PUMP PERMIT <br />