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WELL/PUMP PERMIT 1. <br /> SANPJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT ALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS / �. CITY/ZIP Z-0 -( 5�`� y <br /> m <br /> m <br /> D <br /> CROSS STREET A APN 0L3 1 PARCEL SIZE LAND USE APPLICATION# S <br /> OWNER NAME �Q J� 1 a f . 17 PHONEE`(6 tJ Q73-- <br /> 7 3—�L 7/ � <br /> OWNER ADDRESS // //�� CITY/STATE/ZIP <br /> CONTRACTOR �a-A C� 44,I L 64 PHONE <br /> CONTRACTOR ADDRESS PO I�lO�/►l /) CITY/STATE/ZIPfQ <br /> SUBCONTRACTOR f a _ J5 l�r>, �1L1/,(y PHONE 2~ <br /> -- 3 <br /> SUBCONTRACTOR ADDRESS CITY/^S <br /> �TATE/ZIP <br /> EIC-61 ❑ � <br /> LICENSE le—C-57 C-61 D-09 Other NUMBER '!07338C EXPIRATION DATE�- — <br /> � <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 Uontact Name or Phone Number <br /> TYPE OF WORK A<New Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodotS�(vlud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Dept ¢ 1 Excavation 1`Z in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing_in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-6_ in Thickness/Gauge/ASTM Sched -2-00 ❑Steel XfPlastic El Stainless Steel ❑Other <br /> Grout Seal Depth /OD ft ❑Neat Cement(941b bag/5-10 gal water) >i§and Cement A)� � sack mix17 gal water <br /> F-1 Bentonite(20%solids) F1 Other <br /> Grout Placement Metho Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By E]Driller E]Pump Contractor ❑ Other <br /> El concrete Pedestal EDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP oJeSubmersibleElTurbine ❑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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI I M 4 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76977 <br /> SIGNED / TITLE 0( LJ�C DATE i 7-- 17 <br /> AllnA <br /> N U <br /> ' T <br /> DFP n DTnjELi6E C) NLY <br /> Application Accepted By r J Date ( Area Employee ID# <br /> Grout Inspection By Date E] SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I s ction By Date Constructed Well ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted ervice Request# <br /> 77 11, llot <br /> 0 o 5• 7105 <br /> S <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />