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+, WELL/PUMP PERMIT <br /> SAN Jt)AQUIN C:JUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L v f� CITY/ZIP / <br /> CROSS STREET tii C. ✓ APN W C!— L)/� PARCEL SIZE LAND USE APPLICATION# A <br /> `OWNER NAME LL �� C_._ PHONE <br /> OWNER ADDRESSoilCITY/STATE/ZIP <br /> ! n <br /> L7/ �/7 <br /> CONTRACTOR � �.!�-~ G � PHO�N-E� /yS�r�p— `i' L xa.. <br /> CONTRACTOR ADDRESS ✓� � p"�S CITY/STATE/ZIP /C/.[_/ �/' (lop, ly <br /> SUBCONTRACTOR � PHONE 'J I <br /> L <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 I i Other NUMBER �� �•��T <br /> �• C EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial Ll Water Quality Monitoring Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contac/Name or Phone Number PA <br /> TYPE OF WORK�NeW WellrK' eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11Monitoring Well(s) #of wells U Soil Boring(s) #of borings LI Geotechnical <br /> U Out-Of-Service Well U Out-Of-Service Well Renewal ❑ Cross-Connection Repair °7ry� o <br /> New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing / <br /> WELL CONSTRUCTIONU <br /> Drilling Method�Vlud Rotary L Air Rotary U Auger U Cable Tool LI Push Point LI Other N �I 0 /N�oU <br /> Proposed Well DepthL_t ft Excavation _ in diameter U Open Bottom Gravel Pack/Gravel Size EpAR Teter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched-_� CI Steel elastic (IStainless Steel ❑ Other <br /> Grout Seal Depth�ft u Neat Cement(94 Ib bag/5-10 gal water) and Cement sack mix/7 gal water <br /> ❑ Bentonite 0%solids) ❑ Other / <br /> Grout Placement Method umped ❑ Free Fall I I Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By XDriller U Pump Contractov I I Other <br /> FIConcrete Pedestal ❑Dimensions:Width ft Length ft Thick in Ll Christy Box 11 Stove Pipe <br /> PUMPubmersibleU Turbine IOther HP_,- <br /> 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 /> WORKERS COMPENSATION LAWS. <br /> MIN 24 HOUJ/ADVANCE NOTICE REQUIRED FOR <br /> INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED !�!YJ/C v `6s?!t� TITLE L:J.; jZk tb. DATE <br /> il <br /> 1 • <br /> p <br /> D_E ARTMENT 7E ONLY <br /> A.ppliratinn Accented Fay Date !� Area Employee IC# <br /> Grout Inspection By 1/M Date 7 / 0 SPECIAL Well Permit <br /> Pump Inspection By Date 113 LI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS r—k(ti/l/��/.l �E UA//VS LN �Cf_- <br /> PE Sc Received Chec AmountjDate Permit/ Invoice# Well ID# <br /> Code Ifo ash RemitteService Request# <br /> l 1 ) <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />