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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 /A/ -.^S��/l�(��Y�N Mc{i!� S 1 Ike-C CITY/ZIP <br /> CROSS STREET , {`.,'SSI C. 1 F�Id�-t-.� PIN(y �3W'jLCt PARCEL SIZE II•t Lac AND USE APPLICATION# AIM <br /> p <br /> OWNER NAME W�I ^ &V4, �f`-'�>+ ��L-a PHONE 17/3_Z6Z—;To-9S <br /> m <br /> OWNER ADDRESS �O��,,I_/�SC+L"C �`�CCS l�/�/�.r ,(tk �,� IL CITY/STATE/ZIP -8e c, �J 9 Z-4-16 <br /> CONTRACTOR P)0(7``J I Cj}•!II(1(/i Cf /"1CS_(S.,,D�eG(I cS �{�G'. PHONE 557 aLCJe - <br /> 102-1 <br /> CONTRACTOR ADDRESS ( s Z � r�S"Io J I YC�� CITY/STATE/ZIP � S�1 G v 1 � Z- <br /> SUBCONTRACTOR tJ /A PHONE <br /> SUBCONTRACTODRESS CiTYISTATE/ZIPP q <br /> LICENSE C." C C-61 0 D-09 i Other NUMBER 5-061 S / EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: -I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE L Domestic/Private i7 Irrigation/Agricultural i_ Industrial L'Water Quality Monitoring oil Sampling/Characterization <br /> 7 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK L New Well ❑Replacement Well C Well Alteration/Modification --.Other <br /> D Monitoring Well(s) #of wells iS�oil Boring(s) #of borings ..technical Z <br /> N of borings <br /> 7 Out-Of-Service Well L Out-Of-Service Well Renewal J Cross-Connection Repair A <br /> -1 New Pump I Pump Replacement I Pump Repair Raise Well Casingf .S <br /> WELL CONSTRUCTION M <br /> Drilling Method !Mud Rotary n Air Rotary 'f Auger I I Cable Tool i Push Paint I i Other <br /> Proposed v* Depth 2-C—,e ft Excavation Kl f r in diameter i- Open Bottom I Gravel Pack/Gravel Size in ter FD <br /> ?�b R I r)& 7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched L Steel I Plastic 1 Stainless Steel -1 Other 019 <br /> Groutft t Seal Depth at Cement(94 Ib bag/5-10 gal water) I Sand Cement <br /> TT (20% <br /> sack t�' <br /> 640( !O _;Bentonite(20%solids) I Other H CD <br /> IJ rout Placement Method n Pumped I Free Fall Other Retardant/Accelerator(name) NT/V r <br /> PEDESTAL Installed By i Driller Pump Contractor i Other TM�NT <br /> - Concrete Pedestal 1!Dimensions:Width ft Length It Thick in Christy Box Stove Pipe <br /> PUMP Submersibles i Turbine i•Other HP Pump Set ft Standing Water Level It <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 /> MIN (U/JM'/jd(n8 HOUR V NCE�(,JOTICE REQUIRED FOR INSPECTIONSJ-PLEASE <br /> �Cr(AjLL(209)95 -7697 <br /> SIGNED ��-�x-�/� W W%�� TITLE_ �P�.�SS 10A W Iv'LC DATELltif� / <br /> EP-ARTMENT USE ONLY <br /> Application Accepted By Date Area mployee ID# <br /> Grout Inspection By 'PUADate11 IF 4Z Y141 F S ECTAL Well PerM t <br /> Pump Inspection By Date I i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitte Service Re uest# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />