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r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUND LE PERMIT CALL 209 953-769.7 FOR INSPECTIONS yEEX/PI�R+E,SS I YEAR FROM <br /> ry.DATE ISSUED <br /> JOB ADDRESS — FaXmi-n �... CrrY/ZIP Sl Ul--l-�'�V n 1.J Vt�l•J <br /> CROSS STREET Flzm or, n APN rw^�y�1 L�.,y{/ ARCEL SIZE LAND USE APPLICATION# a <br /> In <br /> OWNER NAME + /i� �/ c.�-��p '-7�q o1� (1�PHONE (, <br /> OWNER ADDRESS ��I1 n�Lj(!/ L1 YQ(U{1tnrrCl-4 CITY/STATE21P.SaL� =1h <br /> CONTRACTOR t\IG(1''r l Com(.( a (- y �M �f PHONE <br /> �9/l�f��36(0-17]01/77 <br /> CONTRACTOR ADDRESS 1_�7S e j Pro,�'r P�1�1��"CP11lSTATE2IP 1�LCYKkQ C4 rdd\lQ�,� I f* l� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 1CrrYlSTATE2IP <br /> LICENSE )(C-57 ❑C-61 C D-09 Ll Other NUMBER,y1`r�+� 0 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391):1 Dibromochloropropane(4392)C Arsenic(4393) <br /> INTENDED USE L Domestic/Private L Irrigation/Agricultural L Industrial a Water Quality Monitoring XSoil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK C New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> C Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal n Cross-Connection Repair <br /> = New Pump 0 Pump Replacement ❑Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method<Mud Rotary L Air Rotary Auger a Cable Tool a Push Point L Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> - Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterin Thickness/Gauge/ASTM Schad 11 Steel C1Plastic C Stainless Steel 11Other <br /> _ <br /> Grout Seal Depth�_ft Neat Cement(941b bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) ❑Other <br /> Grout Placement Method L Pumped -Free Fall Other'CrQ.m\f, ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑Pump Contractor 7 Other <br /> C Concrete Pedestal nDimensions:Width ft Length ft Thick in -1 Christy Box C Stove Pipe <br /> PUMP C Submersibleo Turbine D 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 /> MINIMUM 48 H CEREQUIREDFOR INSAIECTIQNS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE!5y// 7Z Y <br /> DATEri <br /> 4 <br /> E'VLV <br /> 312018 <br /> 0 VA <br /> ALTh <br /> sER14CES <br /> D AR MENT US ON <br /> 10 <br /> Application Accepted By Date �4 A/ Area Employee ID#10�~ <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date JJ WAIVER Received <br /> Soil Boring Ins action By tS.W1,t/l� Date l Lll Constructed Well Depth ft <br /> COMMENTS � i h�y rr�iA/t C ,e� /y�9 /!� 13� v ..i�+�l u&C— <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash R.mitte I Service Request# <br /> SUM <br /> EHD 43.06 revised 4/14/18 WELLIPUMPPERMIT <br />