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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 <br />CALL 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />U <br />I 02094 <br />E C l �� <br />�` I <br />JOB ADDRESS <br />11Z ry� CITY/ZIP <br />�L �Z/ �W <br />CROSS STREETN <br />APN . PARCEL SIZE <br />AND USE APPLICATION # <br />Qp <br />OWNER NAME L� O C. <br />aa <br />U �lh D <br />PHONE 2-09- 214 <br />'1 �/ <br />C4_ O � ) l <br />OWNER ADDRESS PA 00 <br />I EI a h�, M,k R.aA CITY/STATE/ZIP <br />ShLkAVY-1, <br />CONTRACTOR <br />, I S <br />8`/- <br />1 <br />�WY <br />/^PHONE63 <br />�` CITY/STATE/ZIP�o� <br />�� C4: <br />rI_�2-t`V <br />-/✓ �I <br />CONTRACTOR ADDRESS f—� <br />SUBCONTRACTOR <br />PHO <br />SUBCONTRAOR ADDRESS <br />I Y/STATE/ZIP <br />LICENSE C-57 ❑ C-61 <br />❑ D-09 f_l Other NUMBER qM 4a <br />EXPIRATION DATE <br />DOMESTIC ELL SAMPLING: <br />General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1.1 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells I l Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service ell LiOut-Of-Service Well Renewal El Cross -Connection Repair <br />11 New Pump m PUmD Replacement ❑ Pump Repair Ll Raise Well Casinq <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool CI Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I l Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft f I Neat Cement (94 lb bag/5-10 gal water) L Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) Ll Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor f I Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP k Submersible❑ Turbine I 1 Other HP 75 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 />SIGNED <br />- PLEASE CALL (209 <br />DATE , <br />EPRTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection ByDate <br />pp,,, J <br />Pump Inspection By r` M\�� Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />AreaZIAM Employee ID#P&ai <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />,71 <br />m <br />D <br />v <br />0 <br />X <br />m <br />En <br />PE SC Received heck# Amount Permit/ <br />Codes Info By__ ash emitted Date Service Request # Invoice # Well ID# <br />X 159 0 � Z1AVU <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />