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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 /> NOWREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS c L CITY/ZIP �`'�Nti�r-r� �//.� L m <br /> N✓f �J� D <br /> CROSS STREET - I1� APN DL-/ �—" PARCEL SIZF.�(�D USE APPLICATION#_mss o <br /> � n / m <br /> OWNER NAME / &� PHONE <br /> + �y(/y� <br /> OWNER ADDRESS ! 7(i(JWy& <br /> � CITY/STATE/ZIP / <br /> CONTRACTOR Q- -� e� PHONE­!� <br /> CONTRACTOR ADDRESS '� CITY/STATE/ZIP <br /> SUBCONTRACTOR ! d Com►' S / PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 4C-57 [a C-61 ❑ D-09 ❑ Other NUMBER / 2,35 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria(4391)i Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ,F-'Domestic/Private ❑ Irrigation/Agricultural iJ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK *New Well 1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> 1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method,>4%lud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other <br /> ' <br /> Proposed Well Depth.},-f-;— ft Excavation 1`L in diameter I I Open Bottom ii Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/Gauge/ASTM Sched-L-00 I I Steel <Plastic ❑ Stainless Steel 11 Other <br /> Grout Seal Depth ft Ll Neat Cement(94 lb bag/5-10 gal water) Sand Cement (/�.� r sack mix/7 gal water <br /> IJ Bentonite(20%solids) ❑ Other <br /> Grout Placement Methoq,.%e Pumped ❑ Free Fall CI Other I l Retardant/Accelerator(name) <br /> PEDESTAL Installed By -0riller ❑ Pump Contractor ❑ Other <br /> CI Concrete Pedestal i 1Dimensions:Width ft Length ft Thick in ❑ Christy Box F.1 Stove Pipe <br /> PUMP Submersible❑ Turbine I1 Other HPC_ 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 24 HOUR ADVANCE NOTICE REQUIRED FOR <br /> -yINSPECTIONS -PLEASE CALL (209)) 953-7697 <br /> SIGNED .[i[, _ LCf� TITLE L)\.y /� DATE <br /> 2418 <br /> o <br /> O �4. <br /> q�NlY <br /> FNT <br /> EP RTMENT U E OANLY <br /> Application Accepted By Date N t// Area Employee ID# 4 <br /> Grout Inspection By Date 1 1-1 SPECIAL Well Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth &S-D ft <br /> COMMENTS � 'j 1�J at- <br /> PE SC Received eck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> I I I LV()V 6 U) <br /> 05 3 -3 I <br /> I 3. <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />