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WELL/PUMP PERMIT P <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 /> JOB ADDRESS `'� ' 11 CITY/ZIP ! �[J� m <br /> 11 D <br /> CROSS STREET -IQ q I'fDrilaaQp1 IA, APN - V PARCEL SIZE LAND USE APPLICATION# / 2 <br /> OWNER NAME 4� r N1 0YY\_1 I /� p PHONE 090 / - /V/- &Uj Cn <br /> C? <br /> OWNER ADDRESS M1 D� `�`.� G✓. �1�\1-1 CITY/STATE/ZIP � l ��i 1 t l✓1 q52_Q__ <br /> CONTRACTOR 1 1OOYYY�/a xY s.1 V)Cog-'r S_", yyus ]P,H�ON�E a0 I-c,31-321 D <br /> CONTRACTOR ADDRESSL2_0 Wt,CC)X 2pa- CITY/STATE/ZIP,5 wJ }, CA 252z5- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE '(C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 44P 2 s,i((2— EXPIRATION 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 <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 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 ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point CI 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 Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb 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 11 Pump Contractor ❑ Other <br /> Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 1I Other HP P12-Z Pump Set_LQO 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 /> I I U HOUR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76 <br /> SIGN Til E 1 1 DATE <br /> ET F_;444 I I I <br /> t0 <br /> Y <br /> DE ARTMENT U E NLY <br /> C �1 <br /> Application Accepted By Date Area Employee ID# V <br /> Grout Inspection By Date Llt SPECIAL Well Permit <br /> Pump Inspection By '� ��i�11 a,t(►�l� Date IQ ( \L \h 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PAYMENT <br /> PE SC Received Check#V Amount D to Permit/ Invoice D# <br /> o es Info B s Remitted Service Re uest# <br /> 00 v 1 < S "jPco--f;>-5 aCl 0 <br /> SAN UUIN COUNTY <br /> HEALTH DEPARTMENT <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />