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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 /> � <br /> JOB ADDRESS 16-70-1 VON <br /> ON G-114611%Q6111 CITY/ZIP FsQ C co/on / I +320 m <br /> CROSS STREET f vC1 d�] APN 14S-0956—S26 PARCEL SIZE LAND USE APPLICATION# <br /> ]WY� A <br /> OWNER NAME h-t Yt 1'I PHONE kO 3- S 516 y <br /> OWNER ADDRESSmase-1116 <br /> 1 �_I 1VO M & 'ik ky% CITY/STATE/ZIP rSCd&k • q • 5 <br /> 320 <br /> A <br /> CONTRACTOR Iv ase-1 I LS ©ri 111* INC PHONE 522—I 17,9 <br /> C 2S <br /> CONTRACTOR ADDRESS 11 a CITY/STATE/ZIP I��/�gjt5 4 / C.4 `✓✓+ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS /CITY//SSTATE/ZIP <br /> LICENSE �C-57 ❑ C-61 [ID-09 f_l Other NUMBER YJ1q%7,Z EXPIRATION DATE Y-.3 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Char <br /> ❑ Public Water System X11 <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Otherrr <br /> #Ff Arir� <br /> CI Monitoring Well(s) #of wells CI Soil Boring #of borings s) [1 Geotechnical <br /> Out-Of-Service18 <br /> 11 Out-Of-Service <br /> Oif a Well Renewal �� Cross-Connection Repair _ NVONEN UNNE /R <br /> 11 New Pump [IPum Replacement F1 PumRepair Raise Well CasHEALTw <br /> M <br /> WELL CONSTRUCTION rMEIYT <br /> Drilling Method)<Mud Rotary ❑ Air Rotary u Auger ❑ Cable Tool CI Push Point ❑I Other <br /> Proposed Well Depth 00 ft Excavation 12` in diameter uOpen Bottom Gravel Pack/Gravel Size in diameter <br /> Cl Conduct r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched O ❑ Steel ><Pastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodX'umped ❑ Free Fall ❑ Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor [1 Other <br /> Concrete Pedestal DID ons:Width ft Length ft Thick in ❑ 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 /> MINI 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> n _ <br /> SIGNED ` TITLE I�M � DATE /D -2S <br /> N <br /> -A0 <br /> a <br /> s <br /> C� <br /> C <br /> no;. <br /> 010 <br /> DEPARTMENT U E qNLY �f/� <br /> Application Accepted By Date n Area Employee ID#AaL&-' <br /> Grout Inspection By 'tel Date ! Z ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil BoringIn ectio By D Constructed Well Depth q/ `5 ft <br /> COMMENTS `C: jc- t r � <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Wo B ate} Remitted Service Re u st# <br /> /D <br /> 1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />