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;hut Ran 5,15111 <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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /� ` CS/ CITY/ZIP oA Mar C�9 �l5�3I m <br /> D <br /> CROSS STREET FV-y SCA VA Z)11), . APIN os —PARCEL SIZE LAND USE APPLICATION <br /> OWNER NAME � ► 1^ –�I�IJ.J a �G�T T / �C�l�Cj PHONE M <br /> OWNER ADDRESS S A I f l CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑C-57 El C-61 El D-09 E]Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USEomestic/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 � ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> ❑gut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> S;rNew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary E]Air Rotary ❑Auger ❑Cable Tool [-]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter F1 Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑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 ❑Driller E]Pump Contractor ❑ Other <br /> []Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other HP 3 Pump Set / lU ft Standing Water Level <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 2 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE Aa -y' DATE <br /> 44 <br /> Utt' AK I IV] t I U S L U7 LY' <br /> Application Accepted By _Date V7Area Emp(b m "L. 'k,I <br /> Grout Inspection By 1 Date E] SPECIAL Well <br /> Pump Inspection By Date oG ❑ WAIVER ReCeij <br /> Soil Boring Inspection By Date Constructed Well Depth 'Ay2017 ft <br /> COMMENTS SAN J <br /> ENVIRON LUN <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Remitted Service Request# <br /> 3 0 05-C2 �yS 5sN2,60 7-7 p <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />