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�x • 1 I V <br /> WELL/PUMP PERMIT ' <br /> SAN JOAQUIN 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 /> Z.�(. —L�QI�C E50o n `i S 3RD m <br /> JOB ADDRESS C\5!SU S � d.V CITY/ZIP ^,� m <br /> D <br /> CROSS STREET r O�- V n APN2.41 - (5-0 -30 PARCEL SIZE l(p#Lj4_LAND USE APPLICATION# <br /> / ,.� Q ppp,,, cn <br /> m <br /> OWNER NAME L r. PHONE LO Z- L�p-�LC1� cn <br /> OWNER ADDRESS r CITY/STATE/ZIP ��Cd�Yl C 1-1 J 3 1s <br /> CONTRACTOR ( -`, t� Q:i <br /> PHONE S —(L <br /> CONTRACTOR ADDRESS 1 (o LSLj�DI CITY/STATE/ZIP 1 1 1 O�e-S 3 ( �, ( <br /> )� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT <br /> TEE/ZIP <br /> LICENSE C-57 LI C-61 Ll D-09 L I Other NUMBER 2--9in8 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1-1 Soil Sampling/Characterization <br /> 1_I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I_ New Well n Replacement Well ❑ Well Alteration/Modification [IOther <br /> , Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 1 Out-Of-Service Well [.I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> i I New Pump n Pump Replacement I 1 Pump Repair 1.1 Raise Well Casing <br /> WELL CONSTRUC7epth <br /> Drilling Methodud Rotary F1 Air Rotary 1-1 Auger [I Cable Tool Ll Push Point n Other <br /> Proposed Well X� ft Excavation J�A— in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> El Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter$ in Thickness/Gauge/ASTM Sched 5D C2.6 1_1 Steelastic 11Stainless Steel LiOther <br /> Grout Seal D&pth \,,,C)O ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> '[`��entonite 20%Soil ds) Ll Other <br /> Grout Placement Method I umped I I Free Fall [I Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Yleump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ SUbmersibleF] Turbine 11 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 COMPENSATIONt� WS. <br /> INIMUMXHOI ADVANCE NOTICF REQUIR I\NS/P CTIONS - PLEASE 7 <br /> CALL (209)) 953-7697 <br /> SIGNED ITLE �{ r DATE / 3O a CJ <br /> q <br /> C N O <br /> P q <br /> T <br /> PA TMENT U E ONLY <br /> Application Accepted By Date Area I y"/ Employee ID# )�►)Zc <br /> Grout Inspection By Date 0 i ❑ SPECIAL Well Permit <br /> Pump Inspection By Date CI WAIVER Received-� <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS We 11 is V u <br /> h ��nn <br /> , moi' /A r �!l' Q. t 0 �'1 <br /> PE SC Received eck#/ Amount DatePermit/ Invoice# Well ID# <br /> Codes Info s Remitted ice Re u t'# <br /> q,3 cl <br /> l� <br /> jq <br /> I D ► 4 s- <br /> EHD 43-06 8/01/16 .�� WELL/PUMP PERMIT <br />