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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> VON-REFUNDABLE PERMIT / , CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM JDATE ISSUED <br /> JOB ADDRESS III G �l! Al 12 CITY/ZIP <br /> 1 <br /> M <br /> CROSS STREET / �yA�PN - PARCEL SIZE LAND USE APPLICATION# / f <br /> OWNER NAME G C I V 1-t.t PHONE (5-6 ;Z K) <br /> OWNER ADDRESS CITY/STATE/ZIP �j <br /> CONTRACTOR !V .3 PHONEI`�7'/�Z E 2- <br /> CONTRACTOR ADDRESS �'T //// /, CITY/STAT E/ZIne!! "D�/J�M.G/,.- <br /> SUBCONTRACTOR /vG� /�-LILT' PHONE ���jscf Iq <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ?? <br /> LICENSE C-57 ❑C-61 171D-09 ❑Other NUMBER ,� EXPIRATION DATE C' J Ll Cl <br /> DOMESTIC WELL SAMPLING:[General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/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 El Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methocj)mglMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point E] Other <br /> Proposed Well Depth (:k: ' Excavation /2— in diameter E]Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTMSched-2-00 ❑Steel ,Plastic ❑Stain) ssSt–etel ❑Other <br /> Grout Seal De ft ❑Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> ❑ /o solids) ❑Other <br /> Grout Placement Metho Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Lengthft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP *.,jeubmersible❑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 /> MINI M 4 HO R ADVANCE NOTICE REQUIRED FOR <br /> INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> I� DATE <br /> Q <br /> r <br /> v <br /> A U1 <br /> Gil: �n E4LT ENA T1' <br /> E T <br /> I F <br /> EARTMENT U E ONLY <br /> dqol <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By �� Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By (����� Date Constructed Well Depth 3 L (J ft <br /> COMMENTS �/1/�(/�� Ffrj I TAI_ <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes 1 fo ash Remitted Service Request# <br /> 37 0 Fa- -CG <br /> FC C -'fe ' <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />