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WELL/PUMP PERMIT 9 <br /> SAN JOAQ UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FCJR <br /> INSPECTIONS EXPIRES 1 YEAR FR05 DATE ISSUED <br /> JOB ADDRESS / ul'-Zi CITY/ZIP ���� Z- m <br /> q D <br /> CROSS STREET C�!Q APN (�1')._ 1 '�h�A <'PARCEL SIZE L' LAND USE APPLICATION# <br /> �T �j A ( ` <br /> OWNER NAME (7 �) e/� CA ss&k PHONE ` /LTJ ` � y <br /> VA <br /> OWNER ADDRESSy, CITY/STATE/ZIP <br /> CONTRACTOR ('jo'asx o LL�I"J PHONE 3 <br /> 1pCONTRACTOR ADDREESSS�Aer L�a CITY/STATE/ZIP 2 q <br /> SUBCONTRACTOR !t �L PHONE Z2 >1 <br /> 2.0 <br /> SUBCONTRACTOR ADDRESS CIIT7Y/STATE/ZIP <br /> LICENSE ;OC-57 ❑C-61 El D-09 ❑Other NUMBER 1��C-31 EXPIRATION DATE p �� <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private,<1rrigation/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>E New Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑ #of borings SoilBoring(s) []Geotechnical #of borings <br /> ❑ ut-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�tud Rotary El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depthft Excavation & in diameter E]Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched-L.'ZO El Steel Plastic []Stainless Steel ❑Other <br /> Grout Seal Depth $-0 ft E]Neat Cement(94 Ib bag/5-10 gal water) Sand /Cement 10' :3 sack mrx17 gal water <br /> ❑Benton ite(20%solids) ❑Other <br /> Grout Placement Method Jumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor E] Other <br /> E]Concrete Pedestal O)imensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ,&Submersible❑Turbine ❑Other HP -1—r 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 /> MIN=H0 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 955/3-76697 <br /> SIGNED TITLE QLcJ DATE !�-� <br /> 1 U/ <br /> T M <br /> T <br /> F+ <br /> LEPLRMENT SE N L Y <br /> Application Accepted B Aaf&�� Datea7,?/(./ Area Employee ID#�� � <br /> Grout Inspection - ' Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ollDate ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth L53`5 ft <br /> COMMENTS <br /> PE Sc Received KiCheckV Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as RemittedService Request# <br /> 3 l t✓ S C <br /> '256-06 77'5V7 <br /> V�Poo 140 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />