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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 ' - ip i 4s. .-y i.4y)7 rr,4 CITY/ZIP R1 12&--­ m <br /> r' 7 D <br /> CROSS STREET `P," 1 ® A©PN(Z .6--4080- k PARCEL SIZE LAND USE APPLICATION# / A <br /> OWNER NAME `�B✓yL j f[ ' \(LI py"Elm PHONE J -3 <br /> OWNER ADDRESS /Z4 CITY/STATE/ZIPt �n <br /> CONTRACTOR _ S�rZIfISDr, 1 11, <br /> PHONEp�4 <br /> CONTRACTOR ADDRESS ( L L 1 be✓,s R� CITY/STATE/ZIP D!k& 4e GSL r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 r] Other NUMBER EXPIRATION DATE 7 99 1 e9 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Orrigation/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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ 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)'Mud Rotary ❑ Air Rotary LI Auger ❑ CableEter <br /> 1 I Push Point 11Other <br /> Proposed Well Depth�260 ft Excavation 'Zfn I I Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 12—in Thickness/Gauge/ASTM Sched 11 Steel KPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(941b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) Ll Other %10.3 Cctxr'r eke <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other I I Retardant/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 n 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> It <br /> SIGNED �/ � TITLE DATE <br /> w <br /> TMENTZVI <br /> YS E ON LY <br /> Application Accepted By Date Area � Employee ID# � <br /> Grout Inspection By Date ( I PECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspec.on By 1Date Constructed 1Weelll Depth ft <br /> COMMENTS ( 6�1 r3,,, ( ,J �slsf�'1 ,rH^+C1 PAYVE9V7' <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# 'A t�eT <br /> Codes Info Cas Remitted Service Re uest# =ri I i <br /> b i II o <br /> ENVIRO <br /> 1EALTH DEPARTMEN <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />