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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 /> 1 _Ln <br /> T /1^ /��JQ j <br /> JOB ADDRESS • tt�M►YV 1��^ CITY/ZIP ra �N��n ,CD <br /> m <br /> I <br /> A+� I , ^ Q D <br /> CROSS STREET VIA C tsabiit` �) APN ( 17 [ �y«� 3 [d PARCEL SIZE /(W LAND USE APPLICATIIOO(Nj#` 0 <br /> OWNER NAME 1 �,1M 1��� J� PHONE ` •/ `7 - 416 <br /> �f <br /> OWNER ADDRESS Hh A' CITY/STATE/ZIP krm Gy /►A C ✓Q w <br /> ?D <br /> CONTRACTOR 1� tQSC���S ` ,4 PH0NE .c/ �j <br /> CONTRACTOR ADDRESS L Lq Al b fr 7 CITY/STATE/ZIP j YJ�/�6je s4A/ C ` 5357 <br /> SUBCONTRACTOR ` PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 I! C-61 D-09 I I Other NUMBER 60t3s&2L EXPIRATION DATE (-36-/f <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE 'Domestic/Private LI Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring I I Soil Sampling/CharactAWN <br /> r{i �Y�t�op�e <br /> LI Public Water System ff'"' ENT <br /> Ifdifferent from Owner: Water System Name Contact Name or Phone Number EC <br /> EIVEn <br /> TYPE OF WORK %4ew Well Ll Replacement Well I I Well Alteration/Modification [I Other <br /> 11 Monitoring Well(s) #of wells [i Soil Boring(s) #of borings I I Geotechnical b n* 2018 <br /> Cl Out-Of-Service Well L] Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAN JOA <br /> F1 New Pum I.I Pum Replacement F1 Pump Repair ❑ Raise Well Casing JOAQUIN COUNTY <br /> WELL CONSTRUCTION HEALTH DEP'q}�TMENT <br /> Drilling MethoddMud Rotary ❑ Air Rotary I I Auger ' Cable Tool I Push Point I I Other <br /> Proposed Well Depth_ 304? ft Excavation .82: to in diameter I I Open Bottom `)Gravel Pack/Gravel Siz in diameter <br /> Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter inThickness/Gauge/ASTM Sched��� Steel )(Plastic I I Stainless Steel I I Other <br /> Grout Seal Depth ��0 ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bent nite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other -1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I! Driller 'I Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal 'Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP ❑ Submersible ' Turbine Other HP Pump Set ft Standing 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 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 /> MI�JMUM 48 HOUR ADVA NOTICE REQUIRED FOR��INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED �E�� TITLE ✓ rt Me DATE �a <br /> Y <br /> ^ (DEPARTMENT USE ONLY <br /> / <br /> Application Accepted By r '' 1i Date I0 hely Area Employee ID# <br /> Grout Inspection By —c / Date C .Z> r ,jl� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 1 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info 36 Cash Remitted Service Request# <br /> yC1 (� �' '-t ZC� r <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />