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IOPIAP <br /> WELL/PUMP PERMIT <br /> Slav JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> a <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE <br /> ISSUED <br /> Ln <br /> "" CITY/ZIP x/71 -1 <br /> JOB ADDRESS e m <br /> D <br /> CROSS STREET APN ' PARCEL SIZE AND USE APPLICATION# o <br /> y/ Cn <br /> OWNER NAME ACU N PHONE Cn <br /> OWNER ADDRESS CITY/STATE/ZIP ! _ <br /> CONTRACTOR PHONE <br /> �.c o�.D6rJ t- <br /> CONTRACTOR ADDRESS � L)�1" 1 7 13 CITY/STATFJZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT,Ee//ZIP <br /> LICENSE .KL-57 El C-61 ElD-09 [:1Other NUMBER13 //S�y s EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial []Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name Contact Name or Phone Number <br /> TYPE OF WORK>5—New Well ❑Replacement Well ❑Well Alteration/Modification El 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 /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodog:&udr�Rottary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point E] Other <br /> Proposed Well Depth 1 ft Excavation in diameter ❑Open Bottom "K-Gravel Pack/Gravel Size in diameter <br /> F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter--,'� in Thickness/Gauge/ASTM Sched 2'�O ❑Steel ,'Plastic ❑Stainles Steel ❑Other <br /> Grout Seal Depte 0/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 Metho umped ❑Free Fall ❑Other [:]Retardant/Accelerator(name) <br /> PEDESTAL Installed By .gDriller ❑Pump Contractor E] Other <br /> El Concrete Pedestal Epimensions:Width 7 ft Length ft Thick in ❑ChristyBox ❑Stove Pipe <br /> PUMP ;4�3ubmersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> 1 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 /> MINIMU 24 ODUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED-- TITLE l.�1Li��� � DATE 2 <br /> t <br /> NI <br /> r <br /> U <br /> W— <br /> EI IviEN L <br /> H A fHD P <br /> n C o A R T k! E N UF 0 t\I I V <br /> Application Accepted Date �� V Area Employee ID#_{ 7 0 <br /> Grout Inspection y — Date h / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date f>r— Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 3►g as �� 1 1+� � ��► � W o ��w <br /> S� 133V2 ( `51ZD6 7 / OU3g2 5 <br /> 1331 tb I ItvI�R�D7(o( 2(0 <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />