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WELL/PUMP PERMIT ) le ✓ <br /> SAN JOAN UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOIR INSPECTIONS EjXPIRES 1 YEAR FRO5 DATE ISSUED <br /> JOB ADDRESS Z/k E✓Z Al CITY/ZIP m <br /> D <br /> CROSS STREET `k-k,�Q ` APN /y;� a� � ���el �PARCELSIZE��' LANDUSEEAA�PPPLIICATIONN# A <br /> OWNER NAME C J rj �//J �j(�1 �C� �i, �jQ PHONE ` 3- /00-1- ro <br /> OWNER ADDRESS </6 / V CITY/STATE/ZIP v [�� �`��� <br /> CONTRACTOR 17IkASX &W/l"l PHONE 3 (� L 7,LJ <br /> Z�6 1CWP4&� <br /> CONTRACTOR ADDRESS L7 t3 CITY/STATE/ZIP <br /> 1 11 <br /> SUBCONTRACTOR Xi SSL 6 Z2 PHONE Y '1/ <br /> 2.0 <br /> SUBCONTRACTOR ADDRESS CITY/STATTEE/ZZII�P <br /> LICENSE )ZC-57 LIC-61 ❑D-09 E]Other NUMBER <br /> ���w EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General 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 (;ontact Name or Phone Number <br /> TYPE OF WORK,�'New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> #of borings #of borings <br /> El Monitoring Well(s) #of wells E]Soil Boring(s) ❑Geotechnical <br /> ❑ ut-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> Flew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,!;R�Iud Rotary ❑Air Rotary ❑Auger ❑Cable Tool []Push Point ❑ Other <br /> Proposed Well DepthSj? ft Excavation /,(� in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter/0 in Thickness/Gauge/ASTM Sched—L-'O E]Steel y�Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth S-O ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement MethodJzumped ❑Free Fall El Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By AC],Driller ❑Pump Contractor ❑ Other oe <br /> E]Concrete Pedestal EPimensions:Width:�q--ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP „jjj,5ubmersible0Turbine ❑Other HP Z- 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 /> MINIM M�HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209))'9533-7697 <br /> SIGNED « TITLE t',&J/-- DATE (7 /J 17 <br /> OF <br /> RfAl <br /> I X1 <br /> %9 <br /> Vl <br /> T M <br /> T <br /> EP RTMENT �,SfEE NLY .�(.� <br /> Application Accepted B Date / / Area Employee ID#�V t( ib <br /> Grout Inspection - Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth L53j ft <br /> COMMENTS <br /> PE Sc Received eckAmount Permit/ <br /> Codes Info By ZaRemitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />