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zo <br /> 2 S, <br /> WELUPUMP PERMIT P <br /> SAN JC`�,OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEi� 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> [JON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> f <br /> JOB ADDRESS •2TS � _�����✓► L� CITY/ZIP /L�� V( � Z� �� m <br /> �j , /� I D <br /> CROSS STREET `�* [ +L; //w <br /> APN V 6 �00( PARCEL SIZE? l� II LAND USE/A'PPPLICATION# � �? A <br /> OWNER NAME �LZ k u�HONE 7P101 <br /> 4�$ <br /> OWNER AD If2w 'w CITY/STATE/ZIP !9r42,57Z__ <br /> CONTRACTOR �� _� -+ , PHONE [J q� ✓ <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP ,.-'V; 1 <br /> SUBCONTRACTOR G2, �IJS PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> 1 <br /> LICENSE }C-57 F] C-61 F1 D-09 I I Other NUMBER :3 ~7 ? ,iEXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) I Arsenic(4393) <br /> INTENDED USE Cl Domestic/Private Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring LI Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 1-1 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings L,, Geotechnical #of borings <br /> Li Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method�9�/lud Rotary ❑ Air Rotary ❑ Auger Cable Tool LI Push Point Ll Other <br /> Proposed Well Depth ' _ft ExcavationA01 in diameter ❑ Open Bottom I&Gravel Pack/Gravel Size in diameter <br /> I Conductpf Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched'LP I Steel '<Plastic I I Stainl �Steel LI Other <br /> Grout Seal Depth ) ft ❑ Neat Cement(94 lb bag/5-f0 gal water) xzand Cement C/`.i' sack mix/7 gal water <br /> Li Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodaePumped ❑ Free Fall ❑ Other i i Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor ❑ Other <br /> 1:1 Concrete Pedestal ❑Dimensions:Width_ ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP i ubmersibleU 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 24 FJOURADVNCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE!// t- r DATE <br /> �-•-��= d <br /> r <br /> L <br /> 00, <br /> ,>t <br /> k. <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date 2 I Area �lSAE, bfi�Q vi ( <br /> / ' WeTfq� <br /> Grout Inspection By / Date I_I SPECIA L' @hrP� SIT <br /> Pump Inspection By J Date 0 FJ WAIVER Received(, <br /> Soil Boring Inspection By Date Constr ted Wein pth - ` ft <br /> COMMENTS TI �i+1�5�+�C t71�'vwi A u "� - () D r Al. Lem �� © r�(.�►�5 ��1� '�d�. C t <br /> PE SC Received LLbecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> o50 V <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />