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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDAB ERMIT CALL 209 953-7 97 FOR INSPECTIONS 14 4XPIES 1 YE FROM DATE ISSUED <br />(( (� e C a <br />JOB ADDRESS ycl X,• U CITYIZIP <br />CROSS STREET �^ APN CEL SIZE - :KAND USE APPLICATION # <br />"In <br />OWNER NAME r <br />'^ L <br />OWNER ADDRESS lV r �r V <br />PP i EL L 2 -I , <br />CITY/STATE/ZIP C V <br />PHONE V/ V <br />CITY/ TATE TD <br />CONTRACTOR G}'a 1 , Y, r� <br />CONTRACTOR ADDRESS r1 W <br />SUBCONTRACTOR <br />PHONE <br />IV <br />SUBCONTRACTOR ADDRESS <br />CITY/STATES/ZZI�P(� <br />LICENSE C-57 /C-61 D-09 _ Other <br />7 <br />NUMBER 21 0`' `� E%PIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) <br />Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial <br />Water Quality Monitoring - Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name <br />Contact Name or Phone Number <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Boring(s) <br /># of borings Geotechnical # of borings <br />Out-Of-Serviceyell Out -Of -Service Well Renewal Cross -Connection Repair <br />G <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 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 />oncrete Pedestal Dimensions: Width ft Len T <br />h ft Thick in Christy Box 7 Stove Pipe <br />au —M, Submersible Turbine Other HP Pump Set LO U 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 />yl.� <br />MINIMUM 24 HOUR ADVAN NOTICE REQUIRED F R INSPECTIONS - PLEASE CALL (209) 9 3-7697 <br />RE C E TITLE DATE <br />A U 6 z $ 141 <br />ENVIRONMENT <br />PERMIPSE <br />w <br />Application Accepted ByI <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />U <br />P'AftTME <br />Date <br />Date <br />Date <br />C <br />N <br />m <br />O <br />A <br />fNn <br />N <br />-44 <br />CI <br />V <br />2018 <br />COUNTY <br />O N L <br />Area Employee ID#i!!!!4j0~ <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD43-06 a/01/16 <br />WELL /PUMP PERMIT <br />