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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 r/EXPIRES 1 YEAR FROM DATE ISSUED <br /> LA <br /> JOB ADDRESS (N�1/�� G I�/ CITY/ZIP ll��U <br /> CROSS STREET l APN O&/ PARCELSIZE LAND USE APPLICATION <br /> /#� O <br /> OWNER NAME n ��JJ PHONE <br /> OWNER ADDRESS // W,-, . CITYISTATE/ZIP <br /> CONTRACTOR Nell�0. Anderson &Associ/ates, a T'errracon Companv PHONE <br /> CONTRACTOR ADDRESS <'/O vGo�f�r�l� (��L�U�� CITYISTATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATERIP <br /> LICENSE )4 C-57 D C-61 D D-09 D Other NUMBER_669004 EXPIRATION DATE_05/31/2019 <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D DomesticJPrivate D Irrigation/Agricultural D Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br /> 3 Public Water System <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 7 New Well D Replacement Well �i Well Alteration/Modification D Other <br /> Monitoring Well(s) #of wells a Soil Borings) sof boring° XGeotechnical s of borings <br /> D Out-Of-Service Well C Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement ❑Pump Repair ___ _❑_Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method A Mud Rotary D Air Rotary Auger D Cable Tool D Push Point 0 Other <br /> Proposed Well Depth�ft Excavation //-4 in diameter )C Open Bottom D Gravel Pack/Gravel Size in diameter <br /> it Conductor Casing--/-12—in diameter / Conductor Casing Depth J-7�f` ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel J Plastic D Stainless Steel C Other <br /> Grout Seal Depth!?O-'�1,ft >(Neat Cement(94 lb bag/5.10 gal water) D Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) D Other. <br /> Grout Placement Method D Pumped D Free Fall Or Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor u Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box �]Stove Pipe <br /> uMP D Submersible Turbine D 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 /> MINIMUM���48 HH''''OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLFASF CALL(209)953-7697 <br /> SIGNED_ TITLE_Principal — DATE_12/03/18 <br /> PAN, <br /> CF�V�b <br /> C <br /> 0 6 2018 <br /> V %Af C <br /> FA ENTA <br /> =VME,NT UIEDN Y '�// ARTNApplication Accepted By o (?/iC/I Area( Employee ID#� T <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date fC WAIVER Received <br /> Soil Boring Inspection By Date_ L r Constructed Well Depth ft <br /> COMMENTS ri <br /> PE SC Received Check#/ nt Date Permit/ Invoice# Well ID# <br /> odes Info By Cash Remitt d Service Request# <br /> 5 00 <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />