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t101 -- <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 ^ �. CITY/ZIP m <br /> D <br /> 0 <br /> CROSS STREET 1�J , S APN OZ�,a � PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME <br /> / �J/�[s l� L�AYI�i /�'ir PHONE �i/l- «�� ren <br /> OWNER ADDRESS ff �la�` CITY/STATE/ZIP <br /> CONTRACTOR }–f� Cgo-r 7 6-h ,ll q /P'HONNE 3 3 4y �01 J* <br /> CONTRACTOR ADDRESS I CITY/STATE/ZIP 1� L� �L� <br /> SUBCONTRACTOR ��`( �n r PHONE'L� <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 El C-61 [j D-09 ❑Other NUMBER?-2�Lf EXPIRATION DATE-6'—i:7 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private lerrigation/Agricultural []Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK >rlew Well E]Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Wells) #of wells [-]Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> F]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 MethodLd Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth_ ft Excavation in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched [-]Steel Plastic ❑Stainle s Steel ❑Other <br /> Grout Seal Depth�`O ft ❑Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By :[jbriller El Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in [-]ChristyBox ❑Stove Pipe <br /> PUMP „Z'Submersible❑Turbine ❑Other HP 2_0 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 Allo IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINA] U' 4 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED G ,2. TITLE�6�'- DATE t) / <br /> r IV <br /> �' <br /> � Ep <br /> 1 016 ; <br /> Orr L7 <br /> UN <br /> A r N � ' <br /> ENT <br /> 1 <br /> 1 <br /> 4) PARTMENT SE O(�N.,LY /` <br /> Application Accepted Date IZ 'C/ Area Employee ID#1�� <br /> Grout Inspectio B Date �r ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> UIIA-/ U 5&CSC ( I.'t41(�plT(. 1 <br /> PE Sc Received reheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes nfCa--sh Remitted Service Request# <br /> 1 o Pooh <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />