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Tic <br /> WELL/PUMP P jeRMIT ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT /7868 EA*NIAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-769R INS*PEQPOPJS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ♦... CITY/ZIP ] C g N L} " m <br /> CROSS STREET APN C3 11 PARCEL SIZE. �-6`T AND USE APPLICATION# A <br /> UF-) <br /> ' m <br /> OWNER NAME �/ PHONE <br /> LL //y� /J rCA <br /> OWNER ADDRESStion • TY/STATE/ZIP�J A/\ ;� / A <br /> CONTRACTOR a 11 vi ,' ,"- PHONE <br /> CONTRACTOR ADDRESS (C- t liqeliia tIG(/ G�C(�i TATE/ZIP `-4r 6 A 6iS <br /> SUBCONTRACTOR a PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ <br /> lZ <br /> �IP <br /> ' <br /> LICENSE -57 El C-61 1-1 D-09 [j Other NUMBER 4,-&1'/'6C,4/ EXPjff#N DATE rJ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring �OSoil 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 ❑Other <br /> # <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) Geotechnical of borings <br /> F-1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTIONT <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool El Push Point E] Other �ECEFIVPPA <br /> Proposed Well Depth A .5ft Excavation III in diameter [-]Open Bottom ❑Gravel Pack/Gravel Siz In diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> ?,q[nll r: in`7 ^ism��nr in Thiel; BS i a' �;vT"."o�y�.0 I--'St i - last;c v I Steel aS <br /> a3. g _ J ens .., vo�2 ,J P_ �,. ❑ fain SSS Se� <br /> UOGrout Seal Depth ft DdNeat Cement(P4 lb bag/5-10 gal water) E]Sand Cement NVIpaMR40dater <br /> ❑Bentonite(20%solids) ❑Other pEPART _ <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑OtherE]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-1 <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. 1 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 U 2� HOUR YV <br /> ,)k,jN9E NOTICE REQUIRED FOR INSPECTIONS - PLEA/SE CALL (209) 953-7697 <br /> SIGNED , TITLE '-' LtiE Lu' f �bci L"c: / DATE L� r <br /> i \ <br /> 01 <br /> 41 <br /> 77 <br /> V <br /> Id <br /> 01 <br /> i <br /> EPARTMENT USE N L Y <br /> Application Accepted By Date 11911VAP Area AEmployee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date pa Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Request# <br /> RE <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />