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PEL <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> r <br /> NOWREFUNDAE&Wg. CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITYIZIP C"I 1 l(1 b 0 <br /> CROSS STREET APN D�-I�F-S' PARCEL SIZE AND USE PLICATION# a <br /> OWNER NAME HONE <br /> OWNER ADDRESS /t�IV i.. �O/ yy� C ITY/rJ A E/ IP' 7 <br /> CONTRACTOR V �/15/119 a14 ✓V// ✓ J PHON C �I <br /> CONTRACTOR ADDRESS �` [Lcf CITY A7 I ,■may! <br /> SUBCONTRACTORJ-H 1 PHONE •t / <br /> SUBCONTRACTOR ADDRESS ! JITY/S�TTATE/ZIIIP�/y�� <br /> LICENSE C-57 C-61 D-09 Other NUMBER W 1V V EXPIRATION DATE 17, V <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/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(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Wqr Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump VumpReplacement Pump Repair Raise Well Casing <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 S <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel i Plastic Stainless Steel Other (1 <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water ICN <br /> Bentonite(20%solids) - Other <br /> Grout Placement Method Pumped Free Fall Other - Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other O <br /> ncrete Pedestal Dimensions:Width ft Le th ft Thick in -Christy Box vP pe <br /> e <br /> L41 me <br /> PUMP VSubmersible Turbine Other HP Pump Set 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 /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOQQNkPECTION�S-PLEASE CALL(2091 9 <br /> SIGNED TITLE dam/VI/ L�Y�' /_ DATE W G 15 F5 <br /> Pik, E <br /> RECE�v <br /> JAL 13 2 <br /> SN'�SOA ONE U <br /> N��H pEPPR <br /> EP RTMENT USE N <br /> Application Accepted By Date- Area <br /> Employee ID#"' <br /> Grout Inspection By Dal i SPECIAL Well Permit <br /> Pump Inspection By Q�t 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# <br /> Codes Info B Cash Remitted rv' a Re uest <br /> Y ' <br /> EH043-06 6101/16 WELL/PUMPPERMIT <br />