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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 95317697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �O 4C �r1 CITY/ZIP C�H (/`' m <br /> J� D <br /> CROSS STREET APN Z: PARCEL SIZE;ter"ND USE AP; I <br /> OWNER NAME L '�It` �r *,,P'ONE C l I1?1l �/ Cn <br /> OWNER ADDRESS Z L 20.3"/COI STATE/ZIP �b A4-1,W /!_L��� 95 D1 <br /> CONTRACTOR PHONE <br /> Zi <br /> CONTRACTOR ADDRESS 7a CITY/STATE/ZIP P&4 <br /> ? <br /> SUBCONTRACTOR i"���T' PHONE J�___3/Ld <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 I) D-09 LI Other NUMBER3� <br /> k4 -2 365' EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ' General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ,e Domestic/Private L Irrigation/Agricultural L 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 >Vew Well I 1, Replacement Well ❑ Well Alteration/Modification ❑ Other w_ ��,� <br /> Ci Monitoring Wells, #of wells ❑ g #of borings Soil Boring(s)s) i_I Geotechnical l � E <br /> i I Out-Of-Service Well 0 Out-Of-Service Well Renewal u Cross-Connection Repair p f� ,® <br /> ew Pump Ii PLI,np Replacement ] Pump Repair I1 Raise Well Casingtt <br /> WELL CONSTRU TION SqN� <br /> Drilling MethodMud Rotary ❑ Air Rotary El L Cable Tool i l Push Point Ll Other FN OgQU/ <br /> kl NC <br /> Proposed Well Depth",,an ft Excavation 12— in diameter 1.1 Open Bottom 1-1Gravel Pack/Gravel Size HDEp r� meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft MFNT <br /> Well Casing Diameter AC, in Thickness/Gauge/ASTM Sched� _r I I Steel Mastic 11 Stainless Steel 11 Other__ <br /> Grout Seal Depthft _I Neat Cement(94 Ib h,,g15 10 gal water) Viand Cement ZO.. *3 sack mix/7 gal water <br /> LI Ben onite(20%solids) ❑ Other <br /> Grout Placement Method.>4Pumped 11 Free Fall L Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By .Driller 1-1 Pump Contract LlOther <br /> L Concrete Pedestal ❑Dimensions:Widthft Length ft Thick in ❑ Christy Box LI Stove Pipe <br /> PUMP 4Submersible❑ Turbine LlOther 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 /> MINIM IJNI 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7769/7 <br /> SIGNED Of TITLE W/���� DATE p <br /> ci <br /> t <br /> i <br /> DE,4PARTMENT USE ONLY <br /> Appllcation Accopted By 02tc Q,rAa Employee!D# L/ <br /> Grout Inspection By to 7, LI SPECIAL Well Permit �1 <br /> Pump Inspection By ate 1;11i,g pa I] WAIVER Received <br /> Soil Boring Inspection By Datu Constructed Well Depth 220 ft <br /> COMMENTS <br /> PE SC Received Ch Amount Permit/ <br /> Coe Info B Cash Remitted Dat Service Request# Invoice# Well ID# <br /> Z W Poo -3S <br /> Z 1G <br /> o — <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />