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� /r <br /> •, WELL/PUMP PERMIT �' v <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> ANON-REFUNDABLE PERMIT CALL 209 9537697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln <br /> JOB ADDRESS L �Q �[ ,� CITY/ZIP C�N^ (/`� m <br /> J� D <br /> CROSS STREET 3 APN I'- '`� PARCEL SIZE AND USE APP) I P�TIQN b <br /> OWNER NAME G '� �f � PHONE 7 ��C f(1��( _ cEn <br /> n <br /> OWNER ADDRESS n (� I! 2d3'/CIITYIY/STATE/ZIP /✓/lY� / 95 A �a <br /> CONTRACTOR �' ,.PHOONE � 15 <br /> CONTRACTOR ADDRESS Ic / 7e? CITY/STATE/ZIP <br /> l f�k Com/ I✓ <br /> SUBCONTRACTOR (��f' //�" y PHONE 22-7— Ln <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0¢LC-57 Il C-61 U D-09 I I Other NUMBER?736 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE 5e Domestic/Private U Irrigation/Agricultural .] Industrial U Water Quality Monitoring 11 Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >t4ew Well U Replacement Well U Well Alteration/Modification U Other <br /> ❑ Monitoring Well(s) #of wells I I Soil Boring #of borings Is) 1 Geotechnical V <br /> P I <br /> U Out-Of-Service Well II Out-Of-Service Well Renewal _3 Cross-Connection Repair /l <br /> ew Pum I i Pum Replacement U Pum Repair LI Raise Well CasingU <br /> WELL CONSTRU TION SAND <br /> Drilling Method<Mud Rotary U Air Rotary IJ Auger <br /> >> U Cable Tool LI Push Point CI Other ENV/AqU/N C <br /> Proposed Well Depth�_ft Excavation [L in diameter U Open Bottom U Gravel Pack/Gravel Size HDEPaR r� meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft MENr <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched�_du Steel Mastic II Stainless Steel U Other <br /> Grout Seal Depth ft r I Neat Cement(94 Ib h,-01,15-10 gal hater) .Ll&and Cement V sack mix/7 gal water <br /> U Ben onitef (20%solids) _I Other l <br /> Grout Placement Method,'$4_1 Pumped U Free Fall I I Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By %C[Driller I I Pump Contract -1 Other <br /> U Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in U Christy Box I-1 Stove Pipe <br /> PUMP Submersible❑ Turbine Li 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 /> MINIM , 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)[953-/7697 <br /> of <br /> SIGNED A TITLE to W DATE <br /> It <br /> 0 <br /> i <br /> D ARTMENT USE /ONLY <br /> �lcafl led B' 7 Date 6 �V Area Fmnlo ao ID11 <br /> ,1pp, ion,Acc:,p, y - - �-- <br /> Grout Inspection By T E7to _l SPECIAL WBII Permit <br /> Pump Inspection By ate ��u ( I I WAIVER Received 0Soil Boring Inspection By Date Constructed Well Depth J L ft <br /> COMMENTS <br /> PE SC Received Ch Amount Dat Permit/ Invoice# Well ID# <br /> Coqep Info By Cash Remitted Service Request# <br /> 2 Poo -3S-�!>9 <br /> R2 Z aU�$3� <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />