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IF 3 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> ION-REFUNDABIZ PERMIT CALL 209 953-76 7 INSPECTIONS XPIRES YEA DATE ISSUED <br /> IV <br /> (� D L- <br /> JOB ADDRESS 1. CITY21P m <br /> CROSS STREET APNZ07f►V'� ARCEL SIZE LAND USE APPLICATION# a <br /> OWNER NAME t P l 66/t U y/ L Y v - PHO 1� ul, <br /> OWNER ADDRESS &PLIZ y SC CITY/STATE" <br /> 'P <br /> k— Ali <br /> CONTRACTOR <br /> I l// ! `�'•�/ r ,✓� Vl/1 _ 11 p]H�ON/E/ <br /> CONTRACTOR ADDRESS/ ,{,/0 CITY/STATE/ <br /> SUBCONTRACTOR y ' ` -_�r/��r� PHONE <br /> Af <br /> SUBCONTRACTOR ADDRESS, / '� 1C/IITT]YISTTAATEIZIP W `r <br /> LICENSE C-57 C-61 D-09 Oth 1 MB �`-�W 0 EXPIRATION DATE r <br /> DOMESTIC WELLS PLING:- General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) C <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural - Industrial Water Quality Monitoring !- Soil Sampling/Characterization <br /> Public Water System <br /> If different from ro• - Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well - Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBoring(s) #ofborings Geotechnical #ofbonngs <br /> Out-Of-Servic ell Out-OeCross-Connection Repair <br /> New Pum Pum Replacement Pump f-SRe airrvice Well Renewal - Raise Well Casing <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 i Gravel Pack/Gravel Size in diameter <br /> t" Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 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 -i Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width ft Len th ft Thic in Christy Box -.Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It Standing Water Level LX ft <br /> 1 HEREBY CERTIFY THAT HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY O DI NCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTI E ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENS I N LAWS. <br /> MINIM 4 OUR ADV NOTICE REQUIRED FO INSPECTIONS-PLEASE CALL(209q 7697 <br /> SIGNED TITLE 1, _ DATE <br /> RE <br /> S <br /> MAY pqr <br /> ENVIRONNILt RFcFMFNr <br /> D E PA RFf ✓U�O �Q <br /> SMR pv,N ?0918 <br /> Fir <br /> PA TMENT U E NLY <br /> Application Accepted By ate Area Employee ID# <br /> Grout Inspection By to PECIAL Well Permit <br /> Pump Inspection By ttsfl�, i� WAIVER Received <br /> Soil Boring Inspection By Date C st ed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che / Amount Date Permit/ # Well ID# <br /> Codes Info a <br /> emitted Service Request# <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />