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WELL/PUMP PERMIT t' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(109)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> Jos ADDRESS S'z Al ,f 9 TT0-✓ //r/ Cm/LP <br /> CROSS STREET �2/I��d�0�r �&APN �y '�y G�� PARCELSIZLAND USE APPLICATION# (� O <br /> OWNER NAME /V O IQ 4 G� �O C /,fit HON /�.f�� 7V �' 0o' <br /> OWNER ADDRESS 4 7L !1 0 CITY/STATE/LP_ 4x4ft 410V, 9t, /(.r <br /> CONTRACTOR G a A.�u✓ ST PD rA /ASC ?e- _ PHONEt/2 oi) �7 z"-7/ <br /> 79 <br /> CONTRACTOR ADDRESS YS OO � �`.It�ti�4�O� CITY/STATE21P ✓�6���M/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS_ CITY/STATE17iP <br /> LICENSE -C-57 _C-61 ❑0-09 I. Other NUMBER / 7 fIS" EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)'._,Arsenic(4393) <br /> INTENDED USE AfDomeatic/Pdvate '; Irrigation/Agricultural -_Industrial F-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 WORK New Well 7 Replacement Well 7 Well AReration/Modification Other <br /> Monitoring Well(s) #of wells =i Soil Boring(s) #of bonogs D Geotechnical #of borings <br /> Out-Of-Service Well _,Out-Of-Service Well Renewal - Cross-Connection Repair <br /> New Pump Pump Replacement L Pump Repair F] Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary Air Rotary - Auger c Cable Tool n Push Point n Other <br /> Proposed Well Depth _ft Excavation In diameter C Open Bottom U Gravel Pack/Gravel Size In diameter <br /> D Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad C',Steel Cl Plastic D Stainless Steel D Other <br /> Grout Seal Depth ft u Neat Cement(94/b bag/5-10 gal water) a Sand Cement sack mix/7 gal water <br /> Li Bentonite(20%solids) _I Other <br /> Grout Placement Method C Pumped !L Free Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller L Pump Contractor LOther <br /> [,Concrete Pedestal DDlmensions:Width ft Length ft Thick in _,Christy Box - Stove Pipe <br /> PUMP Submersibles-Turbine I Other HP Pump Set ! S✓O 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 48 HO CE REQUIRED FOR INSPECTIONS-PL ASE CALL(209)953-7697 <br /> SIGNED — TITLE /y —�+ / DATE <br /> 4100 <br /> ENT <br /> — I I I I I — _d1___L1 I I I <br /> �Fp <br /> 418 <br /> EPAftTMENT U / Y <br /> Application Accepted By a Date - L Area Employee ID#_(gll� <br /> Grout Inspection Byt_,A�n_ t' f� Date � 'T PECIAL Well Permit <br /> Pump Inspection By PCY L�Ank)Ql ciQ�1�XY Data , `'D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received cliV Amount 0 PermlU Invoice# Well ID# <br /> r!OAS Info milted Service Request# <br /> EH04306 reAsed4/14/18 WELL!PUMP PERMIT <br />