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1111hal Scan 91110 <br /> WELL/PUMP PERMIT <br /> " SAN JOAIPIN COUNT`, En —ONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> iVON-REFUNDABLE PERMIT CALL(299)953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED <br /> 4 2-0 <br /> JOB ADDRESS —L2— ) O( I`� CITY/ZIP t !/ m <br /> i�� D <br /> CROSS STREET' A��1��7�L�'/�r N ^�� U PARCEL SIZE LAND USE APPLICATION# y� A <br /> OWNER NAME Lq�a lL / Sl' r� Tr- PHONE Z 3"` t� v <br /> OWNER ADDRESS A�yt l:' ✓ �CJL+ r-I i CITY/STATE/ZIP ► ��ry <br /> CONTRACTOR o-, "� �" r / PHONE <br /> �j <br /> CONTRACTOR ADDRESS A r3V [-7?? CITY/STATE/ZIPt�dA <br /> SUBCONTRACTOR 0f"Lj PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE//ZIP <br /> LICENSE ,T�-57 ❑C-61 ❑D-09 ❑Other NUMBER: u' S' EXPIRATION DATE 1. <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Orrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name on ac ame or one Number <br /> TYPE OF WORK-,,gNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> E]Out-Of-Service Well El Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodgSlud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter E]Open Bottomravel Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete�,nTM�ess/Gauge/ASTM Sched "� ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depthfl❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method,*g.Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ;kjDriller ❑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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 7NI�M2HOUR ADVANCE NOTICE REQUIRED FO/R�INSPECTIONS - PLEASE CALL (209) 9y53-7697 � <br /> SIGNED TITLE t / i� [ <br /> I, DATE 1-1-7-17 <br /> J <br /> �Q a <br /> Ej <br /> U 1 <br /> D-V F-9 P <br /> s <br /> C7 <br /> J <br /> DE ARTMENT U E /NLY <br /> Application Accepte Date ( -7 AreaA/'�q Employee ID#� <br /> Gout!nspection By J D�ite ❑ SPECIAL Well Permit <br /> Pump Inspection By i ate b E] WAIVER Received <br /> Soil Boring In ection By F site_ G onstructed Well Depth <br /> C 1), a ri <br /> COMMENTS [/UL�O ( cVQ(��—SU✓✓ • <br /> PE SC l R ccs:v hc k'; Amount ermiU I <br /> Date Invoice# Welt ID# <br /> oPodesnfo B LGash 4 emitted Service Request#T�:F. <br /> MWO <br /> - -)- 03 �hll <br /> I° <br /> EHD 43-06 8101116 WELL/PUMP PERMIT <br /> i <br />