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` WELL/PUMP PERMIT <br /> SAN JOA:QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> e <br /> JOB ADDRESS DRQ y <br /> CITY/ZIP�SC ,4 DH 9'f 3 m <br /> CROSS STREET fel /�I/f F p�� APN 2 COS 2�0 2- P RCEL SIZE LAND USE APPLICATION# o <br /> S'Eu On / m <br /> OWNER NAME c-/Qen E <br /> OWNER ADDRESS CITY/STATE/ZIP �y« .-I 9 L <br /> 6 %2 <br /> CONTRACTOR A C <D , /I YPHON� <br /> CONTRACTOR ADDRESS Soo S, /1 �f/lid S✓ CITY/STATE/ZIP 1GLL�'D f/}- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Q <br /> LICENSE �-57 El C-61 El D-09 El Other NUMBER EXPIRATION DATE SSV `J _/ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ngation/Agricultural []Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK EeNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> E]Monitoring Well(s) #of wells El Soil Boring #of borings s) ❑ #of borings;Geotechnical <br /> F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair c��'V <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing S ^.n.a <br /> WELL CONSTRUCTION /i�r7 NnF�n :",; <br /> Drilling Method �d Rotary({!(f Air Rotary ❑Auger [-]CableTool ❑Push Point ❑ Other 4i- <br /> Proposed Well Depth ft Excavation / 2 Al in diameter ❑Open Bottom ravel Pack/Gravel Size ,j)n diameter <br /> []Conductor in diameter / Conductor Casing Depth ft <br /> Well CasingDiameter �� Th' krne /Gau a/ASTM Sched I 's'� estic E]Stainless Steel ❑Other <br /> Grout Seal Depth_ Neat Cement(94 Ib bag I,ate P ❑Sand Cement sack mix/7 gal water <br /> /Be ntoni4pumped <br /> 0°Io solids) F1 Other <br /> hod Grout Placement Met ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in [:]ChristyBox ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 ND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS OMPENSATION LAWS. <br /> M IM ADVANCE NOTICE REQUIRED FOR INSPECTIO S - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE 'fL� 1-eez �f DATE <br /> C <br /> pop <br /> 11 <br /> I <br /> r <br /> m <br /> D PA TMENT PSE ONLY �(,x� <br /> Application Accepted Date Area Employee ID#��uV" <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well DeptV ft <br /> COMMENTS <br /> a� 7�6 A4 �M�K-7 7,,4,li <br /> I 111Z <br /> PE SC Received Check# Amount Dat ermiU Invoice# Well ID# <br /> Codes Ulfo Remitled Service Request# <br /> EHD 43-06 8/01/16 WELL!PUMP PERMIT <br />