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C <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALL ZU`4 904-/bUf FOR INSPECTIONS t.APIKtS 7 TEAR FRO DATE ISSUED <br />JOB ADDRESS �y6 0 5nAb CITY/ZIZIIP <br />CROSS STREET Y/ ]�, /v�•t/�� ✓ APN 2 7� -1-t� 7.J/�(/� PnRCEL SIZE 5. LAND USE�JAPPLICyAATION # <br />OWNER NAME 5%�N /A"N�J�.�� omin6tA .4" I PHONE -o •/w_�-��_ �J <br />OWNERADDRESS/x/0.2 1/`^, �G-,.�,/�=./I z- ' Y0� ` CITY/STATE/ZIP `" � <br />CONTRACTOR W`'r`� �+1`� •'��//PHONE /2- IYr3 <br />CONTRACTOR ADDRESS 5A CITYISTATE/ZIPU -S �/�'y/�l U/�����+/f• r <br />SUBCONTRACTOR R -/l% �- PHONE.2o ?4I - 77041 <br />SUBCONTRACTOR ADDRESS 33 AC� ►CATTY/STTATE/ZIP eA 4157;/. 52 - <br />LICENSE C-57 C-61 D-09 Other NUMBER / 2V D EXPIRATION DATE <br />DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring %poil 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 i Replacement Well i Well Alteration/Modification i Other <br />Monitoring Well(s) # of wells Soil Boring(s) # of borings XGeotechnical # or 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 Air <br />Air Rotary Auger Cable Tool Push Point Other <br />P-Qro,p,oseoWM Depth [D-7,0 ft Excavation 6#1 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />ctv nConductor Casing in diameter / Conductor Casing Depth ft <br />Well CaDiameter in Thickness/Gauge/ASTM Sched i Steel i Plastic I Stainless Steel i Other <br />Grout Seal Depthfo —Z.0 It Neat Cement (94 /b bag/5-10 gal water) i Sand Cement sack man gal water <br />Bentonite (20% solids) ' Other <br />Grout Placement Method xPumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set it 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 />MINIM M 48 U VQNCE NOTICE REQUIRED FORM NfS�Py/Fyyc�TIONS -,PLEASE tCACALL (209) 53-7697 <br />SIGNED <br />�� TITLE r • ' - 17 Pt �4 \ DATE Yi -F(�_b[(![� <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />A MENT U E O Y <br />Date Area Employee ID# <br />Date ❑ SPECIAL @II Permit <br />Date 7 WAIVER Received <br />Date Constructed Well Depth ft <br />0 <br />m <br />N <br />EHD 43-06 revised 4/14/16 WELL /PUMP PERMIT <br />