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WELL/PUMP PERMIT <br /> e SAN JO+AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT \ 1CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J I V�/ So,f,� R n C"/7JP L Cc� 1 ) C A 9m <br /> 1� //ll <br /> ACROSS STREET 1 C APN Q%� PARCEL SIZE II , LAND USE APPLICATION# <br /> OWNER NAME CtY)llt% , PHONE C -, 7 n <br /> OWNER ADDRESS �Iy b /4\IIV� CITY/STATEZP <br /> CONTRACTOR \ , \ ry , PHONElCQ— 27 7y <br /> CONTRACTOR ADDRESS CIN/STATEZP (r711 / A C, ) z D!? <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER2 Q y z (J <br /> �LI C�>u EXPIRATION DATE / J <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 New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells G Soil Boring(s) #of borings Geotechnical #of bonngs <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 /> ) <br /> Drilling Method ,4 Mud Rotary ❑Air Rotary j Auger Cable Tool Push Point Other <br /> Proposed Well /Depth371; ft Excavation in diameter ❑Open Bottom )l( Gravel Pack/Gravel Size lJ4— in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter (j�_in Thickness/Gauge/ASTM Sched (;(, ❑Steel (Plastic i Stainless Steel ❑Other <br /> Grout Seal Depth �( G ft Neat Cement(94 lb bag/5-1 0 gal water) /<Sand Cement I L1.S sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By rnDriller Pump Contractor.. Other <br /> Concrete Pedestal '.Dimensions:Width .D ft Length ft Thick in Christy Box I Stove Pipe <br /> PUMP xSubmersiblei Turbine Other HP J Pump Set J 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 /> MINIM 8 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS-P11,.EASE CALL(209)953-7697 <br /> SIGNED /—"'7 "' - TITLE \<t I C( r 1 DATE 1 I 1 <br /> I V <br /> c ) -E- <br /> WE <br /> W <br /> NT <br /> ED <br /> 2018 <br /> COUNTY <br /> ENTMENT <br /> TMENT U E OApplication Accepted 8Date / / Area Employee ID# /V A / <br /> Grout Inspection By tiDate SPECIAL Well Permit <br /> Pump Inspection ByDate WAIVER Received <br /> Soil Boring Inspection By \d�1 ,? Date Constructed Well Depth Z,7 ft <br /> COMMENTS 1 li ,,a I, <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes fo B Cash Remitted Service Request# <br /> Yl U7 1 <br /> 40 <br /> EHO 43-06 revised 4114/18 WELL/PUMP PERMIT <br />