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f <br /> / 1 <br /> OF 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' 7 CAL 2099) 9p53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS <br /> �Z.'7 1 L �L. /�J" cITY/zIP S %� ,I <br /> m <br /> ] Li' 3� v <br /> CROSS STREET © APN R LI PARCEL SIZE LAND USE APPLICATION# o <br /> / m <br /> OWNER NAME Z <br /> PHONEN�, y <br /> OWNER ADDRESS C 9°tel' '�+ CITY/STATE/ZIP <br /> CONTRACTOR PIS<1C' PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP L,[�-11 <br /> 7 <br /> SUBCONTRACTOR �, 'Z Ql� PHONE _51 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP g <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER3^�7? 6-'t <br /> � EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:®General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)[-]Arsenic(4393) <br /> INTENDED USE ;Domestic/Private ❑Irrigation/Agricultural ❑Industrial E]Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact Name or Phone Number <br /> TYPE OF WORK A*ew Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of borings #of borings <br /> ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method R<Vud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation / in diameter ❑Open Bottom o4ravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter —L,-,X)Thickness/Gauge/ASTM Sched—LEl Steel Plastic ❑Stainlless Steel ❑Other <br /> Grout Seal Depth 2ft ❑Neat Cement(94 lb bag/5-10 gal water) nd Cement A),s —' sack mix17 gal water <br /> ❑Bentonite(20%solids) F-1 Other <br /> Grout Placement Method4!�Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal dimensions: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 %BY 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 /> MI M 2 HOUR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE L-7-Z <br /> s <br /> ,171 <br /> T4 I <br /> rt <br /> it;1P <br /> A. <br /> My <br /> J <br /> Z <br /> n O <br /> W <br /> I t <br /> J <br /> t <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date N ~Z -2 7 Area I , Employee ID# <br /> Grout Inspection By Ntj Date l/ 1/ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date i 24 qD ❑ WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth <br /> COMMENTS U J <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 43(c w1 ,(u 13 0 3 7 <br /> y5 I� z�ll7 vv�%'U3`75L7 <br /> y3K 056 Itl L hIPUO 3_752j� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />