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WELL/PUMP PERMIT <br /> SAN JOAQUIP!COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NQN-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br /> �/F/�rROOM DATE ISSUED <br /> JOB ADDRESS ' CITY/ZIP • V J m <br /> i � D <br /> CROSS STREET APN U UO PARCEL SIZE I S 0 LAND USE APPLICATION#G�ftm r nn (� <br /> OWNER NAME arc !1 PHONE -1�(Y -� I �.0 / 0 <br /> OWNER ADDRESS ro &)X Cl ( CI, (� gj523CP <br /> CONTRACTOR L�/�L`—wiglltIz cdll] t-�—`� PHONE !ll/ !9.�W <br /> 675 C- <br /> CONTRACTOR ADDRE 5 CITY/STATE/ZIP �j <br /> SUBCONTRACTOR PHONE ./ - <br /> SUBCONTRACTOR ADDRESSCITY/STATE/rZIIPP <br /> .0, IL4LICENSE C-57 �C-61 El D-09 I I Other NUMBER (Y EXPIRATION DATE / <br /> 9 JLq <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural U Industrial 11 Water Quality Monitoring ❑ Soil Sampling/Charac <br /> ❑ Public Water System ft&. •ryj <br /> If different from Owner: Water System Name Contact Name or Phone NumbeFlICUE1 <br /> TYPE OF WORK I New Well ❑ Replacement Well ❑ Well Alteration/Modification Ll Other <br /> #of borings of g�o <br /> U El Well(s) #of wells Soil Boring(s) [IGeotechnical 18 <br /> �1' Out-Of-Service Well [I Out-Of-Service Well Renewal Ll Cross-Connection Repair — O Qtlpy <br /> New Pum [I Pump Replacement ] Pum Repair F1 Raise Well CasingROIy CO�N7y <br /> WELL CONSTRUCTION ERARTAgENT <br /> Drilling Method)(Mud Rotary F1 Air Rotary [I Auger [I Cable Tool [I Push Point U Other <br /> Proposed Well Depth ft Excavation _ in diameter i-1 Open Bottom Gravel PacklGravel Size in diameter <br /> ❑ Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in T kness/Gauge/ASTM Sched ❑ Steel [plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth n Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 11 Other <br /> Grout Placement Method CXPumped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> 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 <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�HOUJARWCE NOTICE REQUIRED F=Ad <br /> S -PLEASE CALL (209) -76 <br /> SIGNED TITLE DATE <br /> i <br /> pn <br /> +1 N <br /> 1 <br /> i <br /> D E P A TMENT U E N L Y <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date CI PE AL Well Permit <br /> Pump Inspection B S Date f4 1-1 WAIVER Received <br /> Soil Boring In ection By Date Constructed Well Depth ft <br /> COMMENTS V 1e ,�/ffaW y-1,SM✓lGt oW6 See 4,*6&t-AAW <br /> PE SC Received I CSjWGk*'- Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> .130 1� 3IS ck>k 'l fl <br /> �ry aSu 77 1 (W 20 � 0 0 391 UL <br /> 436 Ia .2ZC'I 1 <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />