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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT ') CALL 20/9)953-7697 FOR INSPECTI S EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓0444 0& O •� �.�CJ � ���� • �(l.( m <br /> IrrIZIP m <br /> Q�IN ��,,r�-p-'� If Qyn D <br /> CROSS STREE I�1�n.'/�.l�I� /yam 0 A'PN;ry_2(9 r�OA//..0. PARCEL SIZE, •�5LAND USE APPLICATION# O <br /> OWNER NAME VE1W* /ITI�y r�� �� l • ? m <br /> ����yy44ffA ]� �/(�/�� PHONE w <br /> OWNER ADDRES9�✓ l0I�/ • Alab R\N/T CfTY/STATEIZIPTR�cy G� 1 -30 lel <br /> 75 <br /> C v/ G.AACiY1M /7f+ ���fi •/�W�I"_— PHONE /e—?742�_!'�r��� <br /> ADDR'E/SS SV-ZJftW X-j?AF&% ' CITY/STATE/ZIoW'✓-4c�/dA­ <br /> y 41•'_ <br /> SUBCONTRACTOR �[ ` ?'j /]i��`T/�•yw' PHONB,, /( _(/�/y(���-7 7OD <br /> SUBCONTRACTOR ADDRESS SS/[�/J��1f.f�(T -J//�• CnYISTATE/ZIP zr f� V 3� <br /> LICENSE C-57 C-61 D-09 Other NUMBER? D X14 EXPIRATION DATE �O <br /> DOMESTIC WELL SAMPLING: 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 i New Well i Replacement Well Well Alteration/Modification i Other <br /> i Monitoring Well(s) #of wells Soil Boring(s) 4 of borings XGeotechnical n of borings <br /> I Out-Of-Service Well Out-Of-Service Well Renewal i Cross-Connection Repair <br /> i New Pump i Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary KAuger Cable Tool Push Point I Other <br /> P12por,ed dk* Depth At ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> twiN�— Conductor Casing in diameter / Conductor Casing Depth ft 3-5?7 Yy <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth � ft )(Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 Driller Pump Contractor I Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in i Christy Box i Stove Pipe <br /> PUMP i Submersibles i Turbine 1 i 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 /> MINI,IIUM,49tg �NOTICE REQUIRED FOR II�INNG�J�-�rCT ONS JPLEASE CALL(209)))953-/76697 <br /> SIGNED ��� TRLE./"•' r I /� DATE <br /> yMFNr <br /> _ ItFi�Fo <br /> ° 134918 <br /> FNT <br /> P RTMENT U E O N LY <br /> Application Accepted By Date Area / Employee ID#44~ <br /> Grout Inspection By Date IWell Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By/ p[M /was Date 72 Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info Cash ternitted kDatj Service Reqat# Invoice# Well ID# <br /> -7 �c <br /> EHD43-06 revised 4/14/18 WELL/PUMP PERMIT <br />