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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL.!!EALTH 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 /> y � d <br /> JOB ADDRESS ObIO_�l_J C1. TTnCnMC7[. Ci CITY/GZ,IP ) m <br /> CROSS STREET 1 1 }-CL/t t-'ra�t L�J,APN c d1-TSIOr) ` PARC�EfLLSD:E :J.1 /LAND USE APPLICATION# A <br /> OWNER NAME LDA, NA.--P e_A sire <br /> r,t D1%5'�i:c PHONE 2o9t-33)) ---72,23 y <br /> OWNER ADDRESS 13oS F yrAP sire e.T CRY/STATE/ZIP �t7i CIT I( 7-T-2-LIC <br /> CONTRACTORV W Df:IIt( /PHONE 1491-/— -77 <br /> CONTRACTOR ADDRESS 1133 B1AC✓LCT�Lfrwt- D'r Nre, CITY/STATE/ZIP Fla t'(-'/ L14- <br /> SUBCONTRACTOR PHONE _ <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE )C-57 ❑C-61 ❑D-09 ❑OtherNUMBER 32L1O EXPIRATION DATE OW�3c 2cZL' <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private D Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soll Sampling/Characterization <br /> ❑Public Water System <br /> If different fmm Owner. wet"System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well ❑Replacement Well D Well AlterationlMo ification ❑Other <br /> ❑Monitoring Well(s) #of wells KSoil Borings) #of borings ' Geotechnical s of borings <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool D Push Point n Other <br /> Proposed Well Depth p IS'_2Sr It Excavation �2 I in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter I? In Thickness/Gauge/ASTM Schad ❑Steel D Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft [Meat Cement(94 Ib bagIS-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped X(Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width It Length ft Thick in ❑Christy Box D Stove Pipe <br /> Pummp ❑Submersible❑Turbine ❑Other HP Pump Set It 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> ��M,� n�1 <br /> SIGNED /"! � TITLE PrFx ' IFp$"Aeer- DATE <br /> bl <br /> DEP TMENT USE ONLY <br /> e <br /> Application Accepted By Date Z Zo 7 Area Employee ID# �I C <br /> Grout Inspection By Data I� ❑ SPECIAL Well Permit <br /> Pump Inspection By Data ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> o i Ir !EL1 <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />