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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 GALL(ZZUy Vb3-/6y/ FOR INSPECTIONS r—Ari r—a II TT LAK I-KUM IUA I r- WJUCU <br />JOB ADDRESS ��T b ��L�/►`�/ ✓r v CITY/ZIP <br />CROSS STREET &feW\ A 'APN r 66 PARCEL SIZE 31 LAND USE APPLICATION # <br />�lii/�(_,��_411/l'1-� O —6� — PHONE <br />OWNER NAME � /—,��_� ! ,y / <br />OWNER ADDRESS I a •� +� L�7I _ /C CITY/STATE/ZIP Lop <br />2— <br />CONTRACTOR �P �ihCo�1 C0�►S til %,�9 �5 ���t 1 / D. � J trSyh PHONE 201 - 3&7 - 32C I <br />CONTRACTOR ADDRESS t 0 2- T v j I IV- i <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP �(%� I '/ C �j <br />PHONE <br />CITY/STATE/ZIP <br />LICENSE ITS C-57 ❑ C-61 Cl D-09 ❑ Other NUMBER h 7OO V' EXPIRATION DATE S7 v/12o1!? <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring oil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well ❑� Well Alteration/Modification 11 Other <br />❑ Monitoring Well(s) # of wells P9'Soil Boring(s) ?— of borings ❑ Geotechnical^N7' <br />❑ 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 />I cu U7 2019 <br />Drilling Method <br />❑ Mud Rotary ❑ Air Rotary XAuger ❑ Cable Tool i i Push Point <br />❑ Other SAN <br />Proposed Well <br />Depth 1-5-20 ft Excavation in diameter Li Open Bottom I I Gravel Pack/Grave O*Twer <br />�V►'I�RO�p��C; <br />D <br />11Conductor Casing in diameter / Conductor Casing Depth <br />ft ""R'v►41 etv 7 - <br />Well Casing <br />Diameter in Thickness/Gauge/ASTM Sched 11 Steel <br />F1 Plastic ❑ Stainless Steel ii Other <br />Grout Seal <br />Depth��Zft XNeat Cement (94 Ib bag/5-10 gal water) <br />❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement <br />Method ❑ Pumped )� Free Fall ❑ Other ❑ Retardant <br />/ Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ 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 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 />MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED `lI /� TITLE 607010 S r DATE 2— _ <br />EPiRTMENT USE ONL1 <br />Application Accepted By Date /07 <br />Grout Inspection By u t Date - <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />Area Employee ID# <br />❑ SPECIAL Well Permit <br />Fl WAIVER Received <br />Constructed Well Depth <br />PE SC Received Che Amount Permit/ <br />Codes Info ash emitted Date Service Request # Invoice # Well ID# <br />2216t <br />2�i-t t70 °i 2-1 <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />m <br />m <br />D <br />0 <br />v <br />m <br />m <br />Cnw <br />