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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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� ( � Y;LejVj+LC r;id�L CITY/ZIP �1�YV j tC(ei �S m <br /> 33 q �/ �y ) D <br /> CROSS STREET D1 I l✓�CO APN .Zo lw �� PARCEL SIZE / rY�LAND USE APPLICATION# o <br /> �^ m <br /> OWNER NAMWWW Al YV-6t <br /> E J /'� B Q LCA PPHO�NNE�,Qlj� <br /> OWNER ADDRESS v O .� (�=� �1— CITY/STATE/ZIP <br /> CONTRACTOR /led C /jl,,/e o,°A 3L PHONE ,/mer –3k 7/ –32C/ <br /> CONTRACTOR ADDRESS IMA CITYISTATE/ZIP_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 F-1 D-09 E]Other NUMBER ��([��/C/�Y EXPIRATION DATE 'J <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Pri,.,ate ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring FIQ&oil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: a er ys em ame Uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> # <br /> El Monitoring Wells) #of wells ❑Soil Boring #of borings s) Geotechnical of borings <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 /> Drilling Method NMud Rotary E]Air Rotary ZAuger El Cable Tool E]Push Point ❑ Other PAYiWizowr <br /> Proposed Well Depth ;�o .5-0 ft Excavation6� in diameter ❑Open Bottom E]Gravel Pack/Gravel Siz ��i I�iweter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft �g e► <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched [-]Steel ❑Plastic E]Stainless Steel Ej,&ir Mig <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) E]Sand Cement SA ._sack mix17 ga water <br /> ❑Bentonite(20%solids) Other Phil,AQUIN COON <br /> Grout Placement Method ❑Pumped E]Free Fall Retardant/Accelerator(name) HELTH AL D <br /> PEDESTAL Installed By r .-Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal EDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑7urbine ❑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 /> MI7U 24 HOU D��CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED ✓) TITLE �'L ) /r (L,fT DATE <br /> c, <br /> r <br /> EP RTMENT U E ON LY <br /> Application Accepted By Date 1 / C Area f1Employee ID# <br /> Grout Inspection By Date ❑ PECIAL Permit <br /> Pump Inspection By � � Date E] WAIVER Received <br /> Soil Boring Inspection By �' E6v►� L�7 � Date )0 Z Constructed Well Depth_ ft <br /> COMMENTS <br /> PE SC Received heck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info a emitted Service Request# <br /> 2� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />