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WELL/PUMP PERMIT <br /> SAN JOAQUID!COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS IV <br /> I CITY/ZIP ' �5 m <br /> ,! `, 15154 <br /> D <br /> CROSS STREET APN V 2 UU PARCEL SIZE 1 S p LAND USE APPLLIC/�ATION#L�� <br /> OWNER NAME -NOU !1 , )PHONE <br /> AP-l 1lYOWNER ADDRESS l CITY/STATE/ZIP Lmdal C-4- 952AP <br /> CONTRACTORrMOM zlrkm <br /> PHONE <br /> CONTRACTOR ADDRE S I . CITY/STATE/ZIP /� Q ✓�j "J <br /> SUBCONTRACTOR I /� <br /> 1 PHONE <br /> ��/_1 �� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 rC-61 CI D-09 Ll Other NUMBER AM(IPEXPIRATION DATE / <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private VIrrigation/Agricultural LI Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Charac <br /> ❑ Public Water System ryJ <br /> If different from Owner: Water System Name Contact Name or Phone Numbe ' <br /> TYPE OF WORK -j New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> U Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical .11 of 8201 <br /> IOut-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair wly jpgQUfN <br /> New Pum [I Pump Replacement Li Pump Repair ❑ Raise Well CasingE=ON COUNTY <br /> WELL CONSTRUCTION EPgRTMENT <br /> Drilling Method Mud Rotary Li Air Rotary ❑ Auger ❑ Cable Tool U Push Point U Other <br /> Proposed Well Depth ft Excavation in diameter i-i Open Bottom YGravel Pack/Gravel Size IN in diameter <br /> ❑ Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in T'kness/Gauge/ASTM Schad LI Steel Plastic ElStainless Steel [IOther <br /> Grout Seal Depth i1 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method iXPumped ❑ Free Fall ❑ Other I 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 /> MINIMUM HOU CE NOTICE REQUIRED FOR INSPECTIONS�r -P EASE CALL (209) -76 <br /> SIGNED TITLE Di.J DATE <br /> i <br /> I god Lo <br /> INJIt <br /> 4 zny 1. <br /> 1191 U <br /> H+i <br /> -- — <br /> — <br /> DEPA TMENT U E JONLY <br /> Application Accepted By df Date l Area Employee ID# <br /> /Z46Zb <br /> Grout Inspection By Date ❑ PE AL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring In ection By Date Con/�tructed Well Depth ft <br /> COMMENTS V t��` 1� o�.SN✓iGt S,CP 1�ac1 � d�/s;/� 9 / .s rtu� <br /> PE SC Received � _ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Regnest# <br /> ,M ci is 3 cf IS ZOfY Ua <br /> �v v ,U y y ( 2f) i 0 c33 <br /> 3 6 1 ) .2 10126K <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />