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1 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT GALLLUy `•75.3-/10U/ FUK INSNLU11UN5 CIU" IKCJ I TtAK I-KUM UAIt ISSUtU <br />a 9s3% <br />JOB ADDRESS I ���� WF CITY/ZIP tia f h <br />CROSS STREET Loy P_ 1,,,C—(W PARCEL SIZ� AND USE APPLICATION # <br />OWNER NAME i� `s'�T /PHONE <br />OWNER ADDRESS M CITY/STATE/ZIP�j _ <br />CONTRACTOR NOU I D C C �SU� �%G �U'� PHONE `D� –✓ 6 3,2o( <br />CONTRACTOR ADDRESS DL ,�. d t. j�✓1 h) �/� CITY/STATE/ZIP !iD I <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE Vd'_/57 ❑ C-61 ❑ D-09 ❑ Other, <br />CITY <br />/ <br />ST <br />ATE/ZIP <br />NUMBER <br />PHONE <br />EXPIRATION DATE S/✓ <br />nnuce-rir Wei i L'AMDI Mrs i (:aneral KAinoral/('.nlifnrm Rarfarin (43911 flihrmmr)rhlnrnnrnnanP (4391) ArsP.nic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I 1 Water Quality Monitoring oil 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 LI Soil Boring(s) # of borings Geotechnical 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 Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other <br />Proposed Well Depth 10 — �- 17 ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/G uge/ASTM Sched I7 Steel CI Plastic Ll Stainless Steel 11 Other <br />Grout Seal Depth ft IuilVeat Cement (94 lb bag/5-10 gal water) I1 Sand Cement sack mix17 gal water <br />El Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑1 Pumped ❑ Free Fall ❑ OtherU9441L ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller n Pump Contractor ❑ Other <br />LI Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine F I 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 />C RRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMI 11&1148 H%O R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)�y953-7697 G <br />SIGNED U �✓�(/ TITLE 6t lJ `y" S � DATE 1-2-S l 15 <br />EP RTMENT U E �LY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date t� <br />Soil Boring Inspection By� 7ryv_ Date /0A L O <br />COMMENTS <br />T <br />-4 <br />m <br />D <br />v <br />v <br />m <br />m <br />co <br />Area 2' C7/J Employee ID# &iyu�p <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />