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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 /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP IY w4c'CG a�J 33 _ m <br /> CROSS STREET APN I'll—1 2p - 1f PARCEL SIZE 2— QArti,LAND USE APPLICATION# <br /> OWNER NAME �` `,, —1 L PHONE 3 I N <br /> OWNER ADDRESS � lQ Li t UVr`T,r`lAQy--,A C CITY/STATE/ZIPyy'S0'(l+eCA, Cpii,- 01' 5 O <br /> CONTRACTOR -t.n 1n:v�d5 rosy• r `���� ()�` PHONE <br /> q';SS\�I,S-� BSc / <br /> CONTRACTOR ADDRESS ` O [Y J CITY/STATE/ZIP 1 1 M�o A CSTL. y_ n <br /> P, _`T7�5'f0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSEC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE 5— <br /> t_20 <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) i Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial u Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKew Well 11Replacement Well ElWell Alteration/Modification 11Other <br /> 11Monitoring Well(s) #of wells ElSoil Boring(s) #or borings (IGeotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> Cl New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation —�I"' _ in diameter 11 Open Bottom Gravel Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter.—& in Thickness/Gauge/ASTM Sched [I Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal DepthJC�0 ft ❑ Neat Cement(94 ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> entonite(20%solids) ❑ Other <br /> Grout Placement Method _ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Deme sions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ 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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUI E R INSPECTIONS -PLEASE CALL (209)) 9533-76197 <br /> SIGNED i7�. TITLE V DATE 3- _L—1 <br /> FW' IE <br /> J A UI U re <br /> DE ARTMENT U)S/E- NLY / <br /> Application Accepted By a Date Area Employee lu?f <br /> Grout Inspection By i Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS` KlSt L W5JI&KS //U <br /> bii9 Q � CsiI WZ( cc — (1.3n <br /> 64,1 C-0 <br /> PE SC Received Check / Amount Permit/ <br /> Codes Info By, Cash Remitted Date Service Request# Invoice# Well ID# <br /> '29 .� I v5 Za l I g �, p np�qy,7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />