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WELL/PUMP PERMIT <br /> SAN JO CIL— <br /> ACI ,OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE.PERMIT G CALL (209053-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP` m <br /> J ' D <br /> CROSS STREET t APN PARCEL SIZE(D�� I LAND USE APPLICATION# 0 <br /> OWNER NAME J s� Cnr' )5+jn 1 PHONE ' /7� ED <br /> m <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTR79-57 <br /> ADDRESS C Y STATE/ZIP <br /> LICENSE [j C-61 F-1 D-09 ❑Other NUMBER4k"40 EXPIRATION DATE 1-5159 <br /> DOMESTI WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> .11 <br /> INTENDED USEDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modificationther Z f111't <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #o borings <br /> ❑Out-Of-Servicer"ell ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump Pump Replacement U—Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter E]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 E]Stainless Steel ❑Other <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 /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP 7ZPump 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 /> MINI R NOTICE REQUIRED FOR I PEyCJTIIIO�JNS - PLEASE CALL (209) 953 <br /> SIGNED TITLE DATE <br /> ` DATE / <br /> 00.1 <br /> 4erlf R N E A <br /> DEPkR <br /> Ty <br /> DE R2t/i -7 <br /> SE ONLY <br /> Application Accepte y Date Area Employee ID# <br /> Grout Inspection By h1 I N Date [ti` ❑ SPECIAL Well Permit <br /> Pump Inspection By i Date 10 13J11 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received VChecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B sh Remitted Service Request# <br /> p b t��9 i to Il S�G� iS 3 2u <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />