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j;r4 h(Ocan <br /> WELL/PUMP PERMIT <br /> ,,SAN JOAQUI.N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> �46N-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES, 1 YEAR FROM DATE ISSUE <br /> .,jB ADDRESS �S� CITY/ZIP CA m <br /> CROSS STREETy�Z APN JA'f2 6 0 n�/ PARCEL SIZE U t ! LAND USE APPLICATION# O <br /> m <br /> 7 m <br /> OWNER NAME 'jam C f c - L1/ 0 <br /> -1 C�� �� 9 J L� /�-+�/��{�j�= f�� PHONE d�� �•' <br /> OWNER ADDRESS f� S� J /Viv y / br�JX CITY/STATE/ZIP V'174001 LI C C I� <br /> CONTRACTOR L�� </ �] /"'(/6/n�� Q_ �,J� ff YT PHONE,. <br /> CONTRACTOR ADDRESS t �j, �( Cc" / t G s-7 (J�(/;r / �5�� CITY/STATE/ZIP //:/1 c r/x (' " <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 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 El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> El Monitoring Well(s) #of wells ❑Soil Boring #of borings s) ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel []Plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb 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 ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By E]Driller Wump Contractor ❑ Other <br /> E]Concrete Pedestal E]Di ensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP CgSubmersibleElTurbine ❑Other HP I. S` Pump Set ft Standing Water Level '13 5 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 /> MI UM 24 HOURDVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697�j <br /> SIGNED u�^ TITLE /L DATE —G7�✓/ <br /> DE ARTMENT U E NLY <br /> Application Accepted Date— 2 I Area Employee ID# c UW <br /> Grout insNecuon by Jate Lj jFRECIa1L Weii F•:�rnnit <br /> Pump Inspection By Date (fi 3 ( ❑ WAIVER Received <br /> Soil Being Inspection By Date Constructed Well Depth ft <br /> COMMENTS _ <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Cod s Info By Cash Remitted Service Request# <br /> EHD 43-03 8/01/16 WELL/PUMP PERMIT <br />