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s 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 /> JOB ADDRESS / c S l .YAG`In C / I rr-c­f m <br /> 1�t� <br /> / PARCEL SIZ AND USE APPLICATION# v <br /> CROSS STREET C-- ►'y�5rn<,�, 1��. APN�IT�-O7O �l� EX m <br /> N <br /> OWNER NAME �� PHONE <br /> rn <br /> OWNER ADDRESS (� �/ (�L� �NCi CITY/STATE/ZIP <br /> CONTRACTOR IG'1 G N 6�/�1 l�e(J i�S�`1� PHONE^7i y -6 3.5 - 6_02'3 <br /> 2 <br /> CONTRACTOR ADDRESS IBJ L C�WI()Y1 J 1 CITY/STATE/ZIPS / 64=1 4gf 2y6'2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP // <br /> LICENSE , C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 6 3C Ile <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) I Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ASoil 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 C1 Soil Boring(s) #of borings Geotechnical _#of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool KPush Point ❑ Other <br /> Proposed Well Depth 2 L) ——So 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 VOtherr2�!li►►)1( F1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor [j Other <br /> ❑ Concrete Pedestal Li 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 /> MINIMUP 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7,619/7 <br /> SIGNED' " `� TITLE V��'Ol�� DATE <br /> .f <br /> T F, <br /> ' Oq <br /> R N` 06 Atz: <br /> P q <br /> r <br /> DEPARTMENT U E ONLY <br /> Application Accepted By — bk�� Date O ( Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date—l L� Constructed Well Depth _ft <br /> COMMENTS <br /> PE SC Received efieAmount Date Permit/ Invoice# Well ID# <br /> Codes Info B s h Remitted Service Request# <br /> 2 -� 22GSr7 WOW <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />