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I <br /> r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMI/T� C/AL 2099/ 9953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> f �L7 ( ��E`• /�J CITY/ZIP f �/ <br /> m <br /> '] L v <br /> CROSS STREET C APN -I k o q ,-) PARCEL SIZE LAND USE APPLICATION# v <br /> f / Ca <br /> OWNER NAME /{ f� �i ( T hG✓�� 5 PHONE /' �6 <br /> Ca <br /> OWNER <br /> OWNER ADDRESS +�C CITY/STATE/ZIP <br /> CONTRACTOR Cy]pi�S'ht'/ PHONE <br /> CONTRACTOR ADDRESS /J ' ` / CITY/STATE/ZIP <br /> — <br /> SUBCONTRACTOR ('00 -fS PHONE L/ <br /> A -f <br /> SUBCONTRACTOR <br /> �7 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 [:1C-61 [ID-09 ❑Other NUMBER 7-?��' EXPIRATION DATE <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 Uontact Name or Phone Number <br /> TYPE OF WORK ;K[Elew Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C<Mud Rotaaryl ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth a c.y ft Excavation in diameter ❑Open Bottom 14Savel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched'LG El Steel 195V31astic El Stainless Steel E]Other <br /> Grout Seal Depthft ❑Neat Cement(94/b bag/5-10 gal water) nd Cement fV -' sack mix/7 gal water <br /> ❑Benton ite(20%solids) ❑Other <br /> Grout Placement Method-<Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width tn ft Length ftThick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP tri 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. ! ALSO CERTIFY THAT MY REQUIRED LICENSE !S <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI M 2 HOUR DVANCE NOTICE REQUIRED FOR <br /> +yINSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE ,��—1-7` 7 <br /> J <br /> A A.161 <br /> I U- <br /> J <br /> Z <br /> Ott <br /> n � <br /> O <br /> W <br /> J � <br /> r-Y f i Li; <br /> • <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date N Area ? Employee ID# 1h�� <br /> Grout Inspection By d-cat­ Date l/ 1! ❑ SPECIAL Well Permit <br /> Pump Inspection By DU 01, 11 Date 1 z, ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS [f JL- <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 4X w Y u13 0 3 "/ I it) 2� n W 3'752--7iCIi y5 vvpUU3�5L� <br /> y3K� a511 a It) t t WPU0325LY? <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />