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/IV Ilj9-d",t:y <br />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 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM ISSUED <br />JOB ADDRESS <br />; <br />L"�hd ��en �e CITY/ZIP 1-4d, <br />{DATE <br />C% <br />r <br />CROSS STREET LL <br />%L/V <br />�Z-4 &J ACPN C1 y�I 3 PARCEL SIZE 41 L� <br />LAND USE APPLICATION # <br />OWNER NAME <br />(, r'1 <br />(36CY <br />/ {! �� %i� `� /S I / 1 Z <br />PHONE <br />OWNER ADDRESS <br />?� <br />4 <br />Cv3L/F <br />�F )'y J� CITY/STATE/ZIP !� <br />/ / <br />4 1i Ir <br />CONTRACTOR /C <br />) <br />1' / <br />�C <br />i4n.� L,;m,r ✓ <br />PHONE - <br />CONTRACTOR ADDRESS` <br />yCC� <br />I7�! �/ I%L� �t//�/1 CITY/STATE/ZIPC <br />-�� <br />SUBCONTRACTOR <br />LL y�,t7�C <br />_ 1'/ �r, <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE C-57 <br />11C-61 <br />El D-09 El Other NUMBER L <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 <br />❑ Replacement Well <br />❑ Well Alteration/Modification ❑ Other <br />[IMonitoring Well(s) # of wells 11Soil Boring(s) a o11 or;ngs X Geotechnical _# o11 or:ngs <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />L New rump a rum <br />WELL CONSTRUCTION <br />Drilling Method <br />Proposed Well <br />Well Casing <br />Grout Seal <br />Ll masse vven <br />❑ Mud Rotary ❑ Air Rotary XAuger ❑ Cable Tool u Push Point ❑ Other <br />DepthI C� _ft Excavation in diameter I 1 Open Bottom ❑ Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Diameter in Thickness/Gauge/ASTM Sched 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />in diameter <br />Depth ft WNeat Cement (94 /b bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other i i Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I I Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible❑ Turbine 11 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 />MI U 48 HO�MNCE NOTICE REQUIRED FO�,R� INSPECTIIONS - PLEASE CALL (209) 953-7697 <br />SIGNED 4i:' TITLE( ,J&ChIli ed /4Gd 6i✓ DATE <br />Ef MEN T U E)INLY <br />Application Accepted By A/2: Date Area AklI Employee ID#04 <br />` r= <br />Grout Inspection By Date 2 ❑ PECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />T <br />-4 <br />m <br />D <br />0 <br />0 <br />m <br />m <br />N <br />N <br />mr-M MW Mm <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />