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WELL/PUMP PERMIT P 1 <br />JAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS JEXPIRES 'I YEAR 7FROM DATE ISSUED <br />JOB ADDRESS4/ r y) L9 CITY/ZIP (moi e/ I <br />7 <br />CROSS STREET ♦✓t/ V✓11 °'� /VLTiZ� APN 6 y�1 f �PARCEL SIZE / C LAND USE APPLICATION # <br />I OWNER NAME <br />OWNER ADDRESS /5� V- <br />I CONTRACTOR I Vei l t. /+Vil otaih <br />CONTRACTOR ADDRESS c( t"t -✓ Y/ �' /C <br />SUBCONTRACTOR <br />ISUBCONTRACTOR ADDRESS <br />LICENSE EX -57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />/ PHONE <br />CITY/STATE/ZIP bO1,}/' 64 <br />S : )) <br />PHONE J'Icl "- / % - )C / <br />CITY/STATE/ZIP /-6141 , <br />7' <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE !�/ I, <br />DOMESTIC WELL SAMPLING: ❑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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification E] Other <br /># of borings # of borings <br />El Monitoring Well(s) # of wells E] Soil Boring(s) Geotechnical 2- <br />El 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 ANT <br />Drilling Method [:]Mud Rotary ❑Air Rotary N&Auger E] Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth=ft Excavation in diameter El Open Bottom ❑Gravel Pack/Gravel Size in diame er <br />E] Conductor Casing in diameter / Conductor Casing Depth ft SEP ' 3 2018 <br />Well Casing Diameter in Thickne/Gauge/ASTM Sched ❑Steel [:]Plastic❑Stainless Steel QRWr <br />Grout Seal Depth ft teat Cement (94 Ib bag/5-10 gal water) E]Sand Cement E�k0w&1 <br />F-1Bentonite(20% solids) HEALTH TAL <br />Grout Placement Method ❑ Pumped ❑ Free Fall "Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ❑Submersible❑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 />WORKER6 COMPENSATION LAWS. <br />MIIWYM 24 HOPr <br />ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 7 TL7 TITLE (i'zi/ r���N/ l" DATE <br />D PA MENT USE ONLY <br />Application Accepted By Date l 3 Id <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection <br />COMMENTS !7I +{ <br />Date <br />Date / <br />_ Date to!) f <br />Area W Employee ID# V V ?�A? <br />❑ PECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />rT <br />.i <br />m <br />v <br />0 <br />m <br />m <br />Cn <br />ur <br />PE Sc Received Amount Permit/ <br />Codes Info B Cas emitted Date Service Request # Invoice # Well ID# <br />7 7 <br />i <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />