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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTO AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABL P T 1CALL 9)1153-ja FOR INSPECTIONS F4PIRES 1 EAR FR DI UED <br /> Y .//�/ N <br /> JOB ADDRESS CITY . • m <br /> CROSS STREET 11 1 �AI APN�)r//' ARCEL SIZE D USE APP CATION# 7 F <br /> OWNER NAME 7n V r a Y '�,('�rP^H'ON <br /> OWNER ADDRESS t U CITY/STAT - <br /> CONTRACTOR`� / a• ✓y \�/'PHH]ONE <br /> �nJ L CI AE P✓ �— <br /> CONTRACTOR ADDRES V <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS/ CITY/STATE/ZIP O <br /> LICENSE C-57 C-61 D-09 Oth r NUMBEZ-140(Q b QXPIRATION DATE <br /> DOMESTIC WELLS LING: General Mineral/Coliform Bacteria(4391) Dibromochloropropene(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System G <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 Wel Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Dump Replacement Pump repair Raise'Nell Casino <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 p <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel . Other -1 <br /> Grout Seal Depth ft Neat Cement(94 Ib 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 Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width It ngth It Thic in Christy Box S!ItEPie <br /> PUMP Submersible Turbine Other H Pump Set it 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 /> `� <br /> WORKERS COMPENSATION AWS. <br /> MINI M 24 H UR AD NCE NOTICE REQUIRED FOR SPEC'TIIONS-PLE/A�S�E/J(�'7ALL(20p��y//q5 -7697 <br /> SIGNED TITLE VV V C�m,}d I DATE 7 <br /> r <br /> PALM <br /> week . <br /> 94 WAqTMEN�USE ONL <br /> Ulo CQj <br /> ion Accepted B D to Area Employee ID# <br /> 51114�oAQU" <br /> VIR� N�ALGrout Inspection By _ Date ' — PECIAL Well Permit <br /> HEALTH OEFA TM�lp Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received dheclo#M Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 6 emitted SA"Vigg Re ues # <br /> EHD43-06 8101/16 WELL/PUMP PERMIT <br />