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1 <br /> WELL/PUMP PERMIT 1 I <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT ^ CALL 209 9553-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS )531-3 1 V• ��G V(e-S R /D,. CITY/ZIP A CA rn?(.1 <br /> CROSS STREET C C�.�U U J 1 _ D <br /> �.r�� ,er R APN PARCEL SIZE LAND USE APPLICATION A <br /> r <br /> In <br /> OWNER NAME `/'J�Wl PHONE r? <br /> OWNER ADDRESS L/ VCJ � CITY/STATE/ZIP <br /> CONTRACTOR \,{A�u Q 7 h L /t <br /> r',)k,,'Y7)�I PHONE -127/-7 <br /> q <br /> CONTRACTOR ADDRESS Y•L` ' &/` ` . CITY/STATE/ZIP G ei 4 ' CA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /K_I �C <br /> JI <br /> ITTY/STATE/ZIP <br /> LICENSE 70-57 /C-61 :I D-09 i s Other NUMBER 3 q E%PIRATION DATE / <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) :Dibromochloropropane(4392)'-i Arsenic(4393) <br /> INTENDED USE A Domestic/Private Irrigation/Agricultural -j Industrial -Water Quality Monitoring i Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different ham Owner: Water System Name Contact Name or Phone Number AYa. <br /> TYPE OF WORK New Well Replacement Well Well Afteration/Modification Other ��ryr <br /> Monitoring Wells) #Of wells Soil Boring(s) #of borings Geotechnical #of bodngs <br /> I Out-Of-Service Well Renewal I Cross-Connection Repair CF��v <br /> I Out-Of-Service Well c <br /> New Pump i i Pump Replacement C Pump Repair a Raise Well Casing <br /> AA <br /> 072018 8 <br /> WELL CONSTRUCTION , <br /> Drilling Method (Mud Rotary -!Air Rotary Auger '-Cable Tool 01 <br /> Push Point - Other X/ <br /> Proposed Well Depth 3A It Excavation in diameter Open Bottom ;�t Gravel Pack/Gravel SizeI QU/NCC <br /> VUI IUUVtU I.GJIII� III UItlIIICICI I Con.I~AUI VtlJllly VClllll a r�M � n' <br /> Well CasingDiameter (}� m Thickness/Gau a/ASTM Sched C�aoi Steel Plastic Stainless Steel Other C R FNT <br /> Grout Seal Depth ✓Ili It C Neat Cement(94 lb bag/5-10 gal water) 15 Sand Cement IG S sack mixn gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped i I Free Fall fOther i I Retardant/Accelerator(name) <br /> PEDESTAL Installed ByDriller L1Pump ContractorI.I Other <br /> Concrete edestal I/Dimensions:Width ,,�ft Length ft Thick=in I Christy Box I!Stove Pipe <br /> PUMP Submersible Turbine 1-Other HP Pump Set-2L C�-_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 /> MINIMU�M4/8 HODU/Rj ADVANCE NOTICE REQUIRED FO`R'INSPECTIONS-PLEASE CALL(209)(95 -76P7_ �J <br /> SIGNED �/"�/ /� TITLE V \�e ��t 7\�('n DATE ZZ 16 <br /> Golf\erg I-L ' 2 <br /> ►2r� S <br /> ►Zo <br /> PA MENT U E LY <br /> Application Accepted By Date J7 Area Employee ID* <br /> Grout Inspection By ate PECI L Well Permit <br /> Pump Inspection By VApt Date `3011Kf i In WAIVER Received <br /> Soil Boring I pection By Date Constructed Well Depth ft <br /> COMMENTS Q <br /> PE SC Received ec Amount Date Pe�It/ Invoice# Well ID# <br /> Codes Ifo sh Re fitted Service Request# <br /> Z-ILI-* <br /> ;� <br /> 0 )?;, <br /> EHD 43-08 revised 4114/18 WELL/PUMP PERMIT <br />