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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-REFUNDABLE PERMIT C 209 53-769 FO INSPECTIONS EXPIRES I YEA ROM DATSSUED <br /> r() JOB ADDRESS CW O / 2 m <br /> �✓ CITY2IP <br /> CROSS STREET [�(// ✓OBD/ PARCEL SIZE:�"OLAND US P IC TION <br /> 1 ]_ <br /> OWNER NAME ��r c7/ �/ /7/�P,/H�^D U`5� <br /> YYY OWNER AODRES lY V Cf �r�cn G CITYISTATE/ZIP `r• ✓ <br /> CONTRACTOR J-tCYJX�11 VVI/V <br /> 1 r ►//T PHONE�tvI � <br /> li <br /> CONTRACTOR ADDRESS I� V U 1 CITY/STATE/ZIP ��/ /-/�'�� `� ZJ <br /> SUBCONTRACTOR NIP PjVNE'• / ' / <br /> IVYP <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 1/9 <br /> '■V/ <br /> LICENSE C-57 C-61 D-09 Oth 211 NUMBER21-7 W(V EXPIRATION DATE 1 <br /> DOMESTIC WELL SAMPLING: General ' eral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) �?1+ <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 Boring #of borings s) Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> �/New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool IPush 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 m <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water `V1` <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped -Free Fall Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ki"Pump Contractor Other 0 <br /> oncrete Pedestal Dimensions:Width ft L n th ft Thick Christy Box Stove Pipe <br /> PUMP V Submersible Turbine Other HP Pump Set ft Standing Water Level IIUU ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 9 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURREN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO RSC MPENSATION LAWS. (1 <br /> U 24 HOU A VAN E REQUIRE FO INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED T LE j DATE (� <br /> N <br /> Ec <br /> xtA Cl ,' EP RTMENT U E ON Y <br /> ME p <br /> Sµ�1vTH ID icatlon Accepted By Date Area Employee ID#1?!�� <br /> Grout Inspection By Date Well Permit <br /> Pump Inspection By ; Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID#41 C77- 1 12 <br /> Inf Ca emitted $��•t R uest# <br /> EHD43-06 6/01/16 <br /> WELL/PUMP PERMrr <br />