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4t lam =2 <br /> • biz "''"�°' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ►ryy CALL 22nn09 953-7697 FOR INSPECTIONS <br /> / EXPIRES 1 YEAR FROM DATE <br /> ISSUED <br /> I JOB ADDRESS CITY/ZIP vn PIA ✓2o <br /> m <br /> tu, 22�- opo-inti <br /> CROSS STREET M O� /�11 a�Q/ APN PARCEL SIZE _LAND USE A�P�jPLICATION# A <br /> OOWNER NAME v v PHONE `[1 �• cn <br /> OWNER ADDRESSy 1 J GJ (�l l,vlit 1 r `^' CITY/STATE/Zipt��f�VV 1 l©1 1n a !19 ✓V <br /> CONTRACTOR /�/ I' 11 PHONE �� 1 -771. <br /> CONTRACTOR ADDRESS L CA Pf\1/�/f s CITY/STATE/ZIPm O` t S 1`)• C9ci 1c,- J C 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS i�C�IT�IY/STATE/ZIP <br /> LICENSE C-57 El C-61 F1 D-09 11 Other NUMBER VY W qT2'7 EXPIRATION DATE v-1 <br /> DOMESTIC WELL SAMPLING: I i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) _I Arsenic(4393) <br /> INTENDED USE VX <br /> Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial [I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from caner: 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 11Soil Boring(s) #of borings LiGeotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other <br /> Proposed Well Depth *DOOft Excavation —t 21 in diameter I l Open Bottom [Gravel Pack/Gravel Size kw in diameter <br /> LI Conductor Casing in diameter / Conductor Casing Depth /` ft <br /> Well Casing Diameter V in Thickness/Gauge/ASTM Sched 200 ❑ Steel APlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 100 ft ❑ Neat Cement(94/b bag/5-10 gal wate/) ❑ Sand Cement sack mix/7 gal water <br /> XBentonite(20%solids) ❑ Other <br /> Grout Placement Method VPumped ❑ Free FallOther (<:::� I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor L-I Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP 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 M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSP��Ejj��CTIONS -PLEASE CALL (209)i9i53r�-,7,8697 <br /> SIGNED TIT V��I►/t/ DATE I I ' V LY• �U 11/ <br /> /I` <br /> 1 <br /> J q <br /> Q N E <br /> R E <br /> D E V A R T M E N I U ' E N L r <br /> Application Accepted B ` Date Area Employee ID <br /> yj/� <br /> Grout Inspection By Date ❑ SPEC AL Well Permit <br /> Pump Inspection By ,) Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 5 0� ft <br /> COMMENTS Ii'L+ �'I' CcLf� �'� Z (G1� ✓1 C' bl, �kGIDY `T.sl <br /> PE SC Received heck Amount Permit/ <br /> Codes Info By_ as a >ittAed t Date ervice Re uest# Invoice# Well ID# <br /> � I ` <br /> EHD 43-06 8/01/16 WELL/PUMP PERMI r <br />