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WELL/PUMP PERMIT <br /> 1 SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDAB RMITCAL 209 9 -7 97 FOR INSPECTION EXPIRES 1 YEAR FROM DATE ISSUED <br /> yJ A <br /> JOB ADDRESS U �/f�- CITY/Zj m <br /> CROSS STREET {� �� �A G �APPNN(4 15 IfJV�(/��PARCEL S12E LAND USE APP C T ON# p <br /> OWNER NAME '/ 1 `�' ✓�/ V Da `7`�b - � w <br /> OWNER ADDRESS / //U C Vt4/�� / CITY/STATE/ZIP 7 (� <br /> CONTRACTOR 0 l, � �/j�aH)ONE L.i <br /> CONTRACTOR ADDRE:B ✓l�� ITy. AT <br /> P ✓ <br /> SUBCONTRACTOR N 1I PHONE •— <br /> �i <br /> SUBCONTRACTOR ADDRESS 77 CITY/S ATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other L./� NUMBEIPL %PIRATION 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 p <br /> Public Water System �+ <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service <br /> ice Vjlell Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum V Pum Re lacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel __Plastic - Stainless Steel Other <br /> Grout Seal Depth it Neat Cement(94 lb bagl5-10 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) T) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Lengthft Thick in Christy Box J Stove 'pe <br /> PUMP Submersible Turbine - Other HP Pump Set ft Stapding Water Level ft <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ` <br /> JOAQUIN COUNTY RDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS C <br /> CURRENT AND AC E WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COM EN TION LAWS. <br /> MINI OUR ADVANCE NOTICE REQUIRO NSPS-PLEAS CALL(209) 1697 <br /> SIGNED TLE �� l� ISL I DATE <br /> PAY <br /> REC <br /> AUG RsAfu1 <br /> o <br /> AUG z 1 <br /> ENVIRONMEN <br /> PERMITISEffiff <br /> PA TENT l5E DIN L <br /> Application Accepted By Date J W Area Employee ID# <br /> Grout Inspection By ItDateIZ__ ___►__. � SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check# Amount Permit/ <br /> Cod Info as Remitted Date Service Request# Invoice# Well ID# <br /> Z, L L Q0.7-110 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />