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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 OOLP <br /> VA Lw.3q.1 'tet CITY/ZIP S(tt'Q n / J J2 0 m <br /> I r n <br /> CROSS STREET C�, ("> 1ok APN 20 S`X00 - 19 PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME Lam/ PHONE �0 J— 376[� rn, <br /> OWNER ADDRESS 114 b /7 S'P�C4-t)Vx 0 CITY/STATE/ZIP FS�d/Ci�, �'� 1�f� <br /> CONTRACTOR M S-( I 1 I SqL[)r I l)I TN{- PHONE—5:/ Z2— /120, <br /> CONTRACTOR ADDRESS I 1 A 1�Qr,S j CITY/STATE/ZIP Mod-r d r]G, (, q , %JA:7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ((CIITY�/ySTAT7E//ZIP <br /> LICENSE KC-57 ❑C-61 ❑D-09 ❑Other NUMBER 10 b!S bLC. EXPIRATION DATE 'L/V <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/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 )<New Well E]Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F-1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 1$Mud RotaryAir Rgtary ❑Auger ❑Cable Tool El Push Point El Other <br /> Proposed Well Depth-114"�' Excavation 17f'* in diameter El Open Bottom (Gravel Pack/Gravel Size in diameter <br /> ❑Cond'uctor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-L- in',Thickness/Gauge/ASTM Sched -2,045 ❑Steel Plastic El Stainless Steel ❑Other <br /> Grout Seal Depth /n U ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Metlhod�>tumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller -%'ump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions: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 /> MINI 24 HOUR ADVANCE NOTICE REQUIRED FOR <br /> /INSPECTIONS - PLEASE CALL (209`) 953f-7697 <br /> SIGNED P 1_� TITLE /�ti1�1P DATE l7 ° 2— <br /> 10 <br /> 1 <br /> L <br /> Q <br /> DEPARTMENT USE ONLY LvlmWA1 <br /> Date / --- f,.reaEm <br /> 111,3/� ployee ID#- <br /> Grout Inspection By Date C ❑ SPECIAL Well Pernniii <br /> Pump Inspection By Dateto I to <br /> E] WAIVER Received <br /> Soil BorjndIns <br /> NTS ction By Date Constructed Well Depth ft <br /> COMM y ?r7 �� ��v c K ri L✓ " ' <br /> G -7- K Sem c l'il/ �,�l..� t-VOSAPLAfdp <br /> E SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> L-d F003 35 <br /> 4311 �rsvvR107 71 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />