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WELL/PUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> I NON-REFUNDABLE PERMIT CALL(209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 3101 K13, j-- ,� 915-304 - K-17 <br /> { n Q gnZP <br /> NP �bFA VAU�1 Q0 APN A39-200-03 2Z% & o <br /> 1 S d r EW UNC { p 1 ,/] J PARCEL SIZE AND USE APPLICATION# <br /> OWNER NAME V1��'�I(�I�GA(�/ a j''N A-L PHONE_�D�1 -3�1- 59-7 <br /> OWNER ADDRESS'3-701^ W• L /Y/V t 9 .� Cln/STATE/LP C 15 3 0�4/�- lW-77 <br /> CONTRACTOR cJ P V M P F-� LL_ S EIL-v i(-�`=I�f C PHONE P1S^--900 !-7.0 <br /> a <br /> CONTRACTOR ADDRESS 20 l0 3 iM k(N &7-- "tS O 7 �Y crryis ATE/LPQftk, : � `iq ( T ��I <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS ( r <br /> C`IITY/STATE/LP <br /> LICENSE EIC-57 ❑C-61 ❑ r_D-09 OtheNUMBER b`� -S-1 EXPIRATION DATE i If-3a <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDeD UsE n Domestic/Private ❑Irrigation/Agricultural LI Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System Z <br /> It different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ' Replacement Well iJ Well Alteration/Modification i7 Other I�r <br /> Monitoring Well(s) #of wells CI Soil Boring(s) #of borings i i Geotechnical #of Barings '1 <br /> ,-i Out-Of-Service Well CI Out-Of-Service Well Renewal I.:Cross-Connection Repair <br /> New Pum -1 Pump Replacement Ll Pump Repair r1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary _Air Rotary D Auger l;Cable Tool n Push Point I Other <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom : Gravel Pack/Gravel Size in diameter <br /> L]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 1 Steel I l Plastic i Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-10 gal water) FI Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method 11 Pumped ❑Free Fall LI Other ii Retardant/Accelerator(name) <br /> PEDESTAL Installed By E Driller t I Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width It Length ftThick in Ii Christy Box F Stove Pipe <br /> PUMP Submersible[:;Turbine r'.Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M NIMUM 48 HOUk ADVANCE NOTICE REQUIRED FO"{j�j;/�INNSPPECTI,O{NS-PLEASE CALL(209)9§2-76,97SIGNED TITLE ( ZE` 51✓ (EADATE <br /> 1 14 <br /> HI <br /> VEPMENT E N/� YJJ1� <br /> Application Accepted B Date f! Area_-;,�y�� Employee ID#//`��?;�` <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#( Amount Date Permit/ <br /> C s Info By Cash fflemittedr Service Re uest# Invoice# Well ID# <br /> EHD 43.06 revised 4/14/18 <br /> WELL/PUMP PERMIT <br />