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Y. WELL/PUMP PERMIT <br /> 'SAN JOAdUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL09 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /J �f mJOB ADDRESS fn <br /> / D <br /> CROSS STREET U APN /�� �/ PARCEL SIZE ��AND USEAPPPLICATION# <br /> OWNER NAME 777�— !4 40/"04f f <br /> � P(H},O�NE!E`' G-( ',6 ''Jj- `02 ,( N <br /> OWNER ADDRESS lsxlylo t,! 1003 CITY/STATE/ZIP I/I V�J t r <br /> CONTRACTOR t+ C os-,r PHON�E ���I /�L <br /> CONTRACTOR ADDRESS I CITY/STATE/ZIP�b(//J&1&1 fitj <br /> SUBCONTRACTOR ' .]�+ PHONE�)-7 " <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ' 1 <br /> LICENSE -57 El C-61 El D-09 [j Other NUMBER�( :7-VS EXPIRATIONDATE �✓ <br /> DOMESTIC WELL SAMPLING:UGeneral Mineral/Coliform Bacteria (4391)[ADibromochloropropane(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 Contact Name or Phone Number <br /> TYPE OF WORK >ISNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑ #of borings Soil ❑Geotechnical #of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method<Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth S ft Excavation in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6' in Thickness/Gauge/ASTM Sched 72-02 ❑Steel Wlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 2_Oa ft ❑Neat Cement(94 Ib bag/5-10 gal water) P$and Cement 1 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method t�'Pbmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller [:]Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick 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 /> MI�N,/IJP-fM 4 HH UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)/953-7697)7 <br /> SIGNED `!�j / l/t.V`- TITLE �/W r (S�` DATE <br /> i <br /> CP <br /> S N <br /> FA Vj N O <br /> E L <br /> DE ARTMENT 'SJ�E O LY r <br /> Application Accepted By a Date v' 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 ft <br /> COMMENTS <br /> PE Sc Received Check Amount Permit/ <br /> Code fo 'tt <br /> ash emed Date Service Request# Invoice# Well ID# <br /> d 2 Il UO 7o 0 <br /> L3 i -7 7 1'60 7 <br /> 11 0.7� CI-4- 0 3 0 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />