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,/ti/= /:3) —JXI(-;41 scae) (OPI r(P <br /> "A'a1v- <br /> ! -" -el) WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUWDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS �/ I�/ : + CITY/ZIP /� r/L1 m <br /> a <br /> CROSS STREET ✓ 0-4 APN �^ ' PARCEL SIZE AND USE APPLICATION# o <br /> .Li m <br /> OWNER NAME ALU PHONE <n <br /> ,{ en <br /> OWNER ADDRESS �/d CITY/STATE/ZIP <br /> a <br /> CONTRACTOR ��? r�� �1L�rO/LL PHONE <br /> � <br /> CONTRACTOR ADDRESS /LJti7" [ �t� CITY/STATE/ZIP 6C W'D rj / <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE F!wrL-57 El C-61 ❑D-09 ❑Other NUMBER��.7yOs 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: V Va-Fer ys em ame Contact Name or Phone Number <br /> TYPE OF WORK>S—New 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 /> �kNew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.>KPud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth— �L-> ft Excavation j"L— in diameter ❑Open Bottom ,Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ,Plastic ❑Stainles Steel ❑Other <br /> Grout Seal DeptF� j ft ❑Neat Cement(94 Ib bag/5-10 gal water) *Sand Cement lJ>-3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method>QPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By .[Driller ❑Pump Contractor E] Other <br /> ❑Concrete Pedestal dimensions:Width 7 ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP —S 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 <br /> 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED -o L!� TITLE l 1p��! L I z e-- DATE /0 - -2rn <br /> I'� <br /> t1 <br /> E VI N L <br /> H A H.DqPjRTfWqR <br /> V E O A D T M C_ T_ 11 S E 0 AI 1 V <br /> Application Accepted IR AI Date ?7� C7 Area Employee ID#_� 7 <br /> Grout Inspection y Date h / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 1 ❑ WAIVER Received <br /> Soil Boring Inspection By Date C Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#I Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 31'g d" ISo -7(-1 �!' 0 3uW <br /> 133 V8 vo 3► kyjo S(ZD6 7 / ())3°12 5 <br /> 1331 tb ► Uo sR�o 7�l 2(0 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />