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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />�y j, _ �� <br />GALL ZUy U*J-/'0Uf FOR lN5PEGTIION5 r-Arimmo l Utt <br />TtAK I-KUM AIcIJJUU <br />JOB ADDRESS �ffC 0, 2 Sil4Fif�-.�A VL�!'LG� Rd. CITY/ZIP <br />CROSS STREET T/ // �/ APN �, �7' �nrJ I© PARCEL SIZE :L LAND USE APPLICATION # <br />iOWNER NAME I /JrGI!) S��rl ll /J /PHONE /— <br />OWNER ADDRESS iPC��t �YI 9 �. I PMC/1 h 15 CITY/STATE/ZIP ( Z 2 7 <br />CONTRACTOR n C O. PHONE _3o1) 2�2_3 -373 <br />CONTRACTOR ADDRESS G/ eNCLAWel CITY/STATE/ZIP <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE V C-57 ❑ C-61 ❑ D-09 ❑ Other, <br />NUMBER <br />CITY/STATE/ZIP <br />PHONE <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private 0 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 Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump V Pump Kepiacement ❑ Pump Kepair 11 Kaise vveu �,asmg <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 <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft I I Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall 1 Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller IJ Pump Contractor 11 Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Id Submersible❑ Turbine f 1 Other HP�!Z_ Pump Set 3 �✓ 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 />\MINIMUM 48 HOU�DVNOTICE REQUIRED FOR INSSPE CTIONS - PLEASE CALL (2 ) 953-7697 <br />SIGNED: � �TITLE` [/{'I l /r' /' DATE ! <br />C, r R N1E�tT t.'e E OyI Y <br />Application Accepted By Date <br />Grout Inspection By <br />Date <br />Pump Inspection By KWIi hqL& ,\\AW Date l U_W — <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area Employee ID# <br />1-1 SPECIAL Well Permit <br />F1 WAIVER Received <br />Constructed Well Depth <br />ft <br />q JOAQUIN COUNTY <br />EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />T <br />1 <br />m <br />D <br />0 <br />0 <br />X <br />m <br />