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WELL/PUMP PERMIT ✓ <br /> SAN JOAQUIN COUNTY ENVIR NMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE <br /> PER CALL <br /> (209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATE ISSUED <br /> JOBADDRESS `��I 0 ✓/t Crryli <br /> 12dLAND USE APPLICATION#CROSS STREETADQ ' APNN _ O —1 —PARCELSI <br /> rn <br /> OWNER NAME Va0(5;eDZZ4 ic—�At— <br /> PHONE <br /> OWNER ADDRES3303 S CITYISTATEIZIP&gQ/. MLE yf 2' yno <br /> •O^l <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDR"EES�S��J J���)/�+� CITYISTATE/Z1P <br /> 9MCONTRACTOR •T " �✓'�•Q�I 4'�,-, PHONE —" / rV ` • •K� <br /> a.CONTRACTOR ADDRESS I I-5:5; k&grr—1>e - CRYISTATE/ZIP /�_ rick 3 z- <br /> LICENSE ,(C-57 C-61 D-09 Other NUMBER 7 •TAD EXPIRATION DATE <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private C Irrigation/Agricultural Industrial Water Quality Monitoring >(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 Afteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) a cf parings VGeotechnical 77 of borm9a <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 'I Air Rotary X Auger Cable Tool Push Point ❑ Other <br /> 1 <br /> P posed 1Wi1 Depth56ft Excavation, iV in diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched i Steel Plastic Stainless Steel Other <br /> Grout Seal Depth1�W�ft XNeat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped = Free Fall Other M Retardant/Accelerator(name) <br /> PEDESTAL Installed By L Driller - Pump Contractor Other <br /> Concrete Pedestal 7Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP SubmersibleG Turbine Other HP Pump Set It 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 COMPEN TI LAWS. <br /> MINIMUM& O0URQ(A,NCE NOTICE REQUIRED FOR INSET ONS-PLEASE CALL(209)953-7697/ <br /> Si �!� TITLE S+T {� ��+FI� DATE _`� <br /> IGNED <br /> �001!0 <br /> � <br /> v�N NCP�- <br /> oEpP��M� <br /> PA TMENi�t7 <br /> /�M�Application Accepted B / Date Area Employee ID#A�/•Y/VJy—' <br /> Grout Inspection By_ Date ECTAL Well Permit 1 <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck*/ Amount Permit) <br /> Codes Info B as Remitted Da Service Request# Invoice# Well ID# <br /> EHD 4106 8101/16 <br /> WELL!PUMP PERMIT <br />