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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 /> 1.ON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIR S 1 YEAR FROM DATE ISSUED <br /> OB ADDRESS / � 1��/j/�' c CITY/ZIP tet, r m <br /> CROSS STREET n7 ' /AAPN_��I� �DJ PARCEL SIZE LAND USE APPLICATION#'� v <br /> OWNER NAME / /(/f(<Y,.", r �z� ��. / /�n o jjl I PHONE ! —�nVy vi <br /> OWNER ADDRESS �<yD///" l / 13v Y/�/ I/yFy SIV CITY/STATE/ZIP <br /> CONTRACTOR �r^L�'� PHONED <br /> CONTRACTOR ADDRESS �v �/T� CITY/STATE/ZIP 4_z J l�� <br /> SUBCONTRACTOR � � �� PHONE 37u <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 7 <br /> LICENSE XC-57 El C-61 El D-09 ❑Other NUMBER 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 System Name contact Name or Phone Number <br /> TYPE OF WORK ew Well ❑Replacement Well [:]Well Alteration/Modification ❑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 Methoo"KIMuud�dR��,o,,ttary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point El Other <br /> Proposed Well Depti;W ft Excavation in diameter E]Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter-46' in Thickness/Gauge/ASTM Sched _ ❑Steel Plastic F1 Stainless Steel [-]Other <br /> Grout Seal Depths _ft ❑Neat Cement(94 lb bag/5-10 gal water) NSand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Ournped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller El Pump Contractor ❑ Other <br /> El concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 146 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 /> MINIM 24 OUB ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)) 9s53-769/7 <br /> SIGNED r TITLE V DATE <br /> O <br /> H11 <br /> A M <br /> EPA TMENOUE ON Y <br /> Applic tion Accepted By Date Area Employee ID#Gr t Inspection By Date " ❑ SPECIAL Well Permit <br /> Pum nspection By ( -- Date T ❑ WAIVER Received <br /> Soil Boring Inspection,By Date Constructed Well Depth ft <br /> COMMENTS AIGIt ,• ��`+T/���C 4a I c 71D_# <br /> PE SC Received Check# Amount Date Permit/ Invoice# Wel <br /> Codes Info B Remitted Service Request# <br /> & " Z3 1 0 I &T 4 foo <br /> �' I � t/5 U � 7� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />