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d <br />Application Accepted By Date /iv/_ Area-4VCf6t Employee ID# Al (fvb <br />Grout Inspection By Date _ SPECIAL Well Permit <br />Pump Inspection By Date 1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD4306 6/Ot/16 <br />WELL /PUMP PERMIT <br />PA <br />05 2018 <br />OAQON <br />F CO <br />rk <br />T <br />V/ <br />• WELL/PUMP PER <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELToN AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE,PERMIT CALL 209 9§3-769!0F INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />W <br />JOB ADDRESS v CIN yl (C4 <br />1 2,C) ' S¢ AND US PPLICATION # <br />N <br />m <br />D <br />p <br />CROSS STREET APN CEL <br />C PjiONE <br />OWNER NAME <br />C <br />TA / IP <br />-- <br />OWNER ADDRESS <br />IA '.�1y', +f—CITY/ <br />CONTRACTOR L(A r ' ' ` ✓ n PHONE <br />3 <br />Uq f <br />' A�� <br />CONTRACTOR ADDRESS �� 4 y, CIN/S ATE ! <br />PHONE <br />S <br />SUBCONTRACTOR / 1 <br />SUBCONTRACTOR ADDRESS ' Ilia �T�ST1AT^EI/ZInP/w� <br />� <br />NUMBER po[�/ 1 XPIRATION DATE <br />LICENSE C-57 C-61 D-09 Oth W <br />DOMESTIC WELL S LING: 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 Wells # of wells SoII Borings) # cf lwnngs Geotechnical A of borings <br />Out-Of-Servi ell Out -Of -Service Well Renewal . Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />_ <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />\ ) <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 />Grout Seal Depth ft Neat Cement (94 Ib 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 I Accelerator (name) <br />QN <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft L gth ft Thitk in Christy Box StqM Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level <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 />^' <br />\ V <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR �ADVANCE <br />• NNOTIICCE REQUIRED FO•VNNS^P/E/C)TIONS -- PPLEE.ASE CALL (209) 317/6 {9�/7y� % G <br />------- �/L LF�ar�l�! wrF Tits )IMI ! (Q / Y I.N/7 DATE E ! `' / b <br />d <br />Application Accepted By Date /iv/_ Area-4VCf6t Employee ID# Al (fvb <br />Grout Inspection By Date _ SPECIAL Well Permit <br />Pump Inspection By Date 1 WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD4306 6/Ot/16 <br />WELL /PUMP PERMIT <br />PA <br />05 2018 <br />OAQON <br />F CO <br />rk <br />T <br />