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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS (EXPIRE 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP �j� �� S �� m <br /> CROSS STREET A)N U PARCEL SIZE <br /> / ' D <br /> y� y� I . ND USE APPLICATION# 1 <br /> U(2 <br /> A <br /> OWNER NAME �R PIC,-, �-Ijaal I )C(`�I^I L'l �FJl)) TTT� �tj' IYH / /) <br /> ONE�G� / 0— Cvi <br /> OWNER ADDRESS ��/Y7//� / e-0 bX :ZQ3 Q CITY/STATE/ZIP <br /> CONTRACTOR /� (7 �tL �� PHONE �Sr�' <br /> CONTRACTOR ADDRESS <br /> �/� /"G� � l � CITY/STATE/ZIP <br /> SUBCONTRACTOR l ?/` �K LJ (���/ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �C�57 El C-61 [I D-09 E]Other NUMBER/ /Jff EXPIRATION DATE <br /> 6"-Z';' <br /> DOMESTIC WELL SAMPLING:RGeneral Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/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 SiofAlew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> #of borings #of borings <br /> ❑Monitoring Well(s) #of wells ❑SoilBoring(s) ❑Geotechnical <br /> F]Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair `°r Ir ' , 2017 <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing Sq <br /> WELL CONSTRUCTION ENVIRON O(J/yn, <br /> Drilling Method. . ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other HF�LrN DE MENTpL <br /> "" <br /> Proposed Well Depth v ft Excavation G' in diameter ❑Open BottomGravel Pack/Gravel Size in diameter <br /> ❑Conductt Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter"` in Thickness/Gauge/ASTM Sched ❑Steel Plastic El Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94/b bay/5-10 gal water) 'JSand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method%4jtPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By $Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width 1 ft Length ft Thicker in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑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,HOU <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED 1 3' TITLE ���r 't� DATE <br /> tt r <br /> A <br /> r r <br /> M1 ` <br /> PARTMENT USE ONLY <br /> Application Accepted By Date Q- 0 —/ Y Area I Employee ID# <br /> Grout Inspection By NAF9614 A&AiI Date 17-11 Z--,/7 SPECIAL Well Permit / <br /> Pump Inspection By _ Date 'L ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3z6 ft <br /> COMMENTS 17 It 9 <br /> KCodes <br /> SC Received C Amount Date Permit/ Invoice# Well ID# <br /> Info ash Remitted Service Request# <br /> �6? .D- �� <br /> �5 �' 3 1 3 y <br /> EHD 43-06 6101/16 71�� �//'� /n� _ Il (1 ��* ���'/�., �� WELL(PUMP PERMIT <br />