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I t 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 95>3-7697 FOR INSPECTIONS EXPIIIRRES�1 YEAR FROM DATE ISSUED <br /> < CITY/ZIP ��/' "� N <br /> JOB ADDRESS m <br /> D <br /> CROSS STREET //��AwwPN "� ��/}��PARCEL SIZEQ-�_ LAND USE APPLICATION# a <br /> OWNER NAME �� Lel"/�h ��/ENVI�� PHONE / -.?1—7���� _ <br /> v� <br /> OWNER ADDRESS CCIIITTYY/STATE/ZIP —� <br /> CONTRACTOR / �G/���/ � T � � �- PHONE <br /> CONTRACTOR ADDRESS G[� ��f! r,�i� CITY/STATE/ZIP !' / ✓��� <br /> SUBCONTRACTOR /L'/ L�� /�//�/ PHONE <br /> SUBCONTRACTOR ADDRESS - CIT <br /> Y/STATE/ZIP <br /> LICENSE -57 -61 ❑ D-09 ❑ Other NUMBER L/N�� EXPIRATION DATE / �l <br /> DOMESTIC WELL SAMPLING: i i General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial _1 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 eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring ell(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <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 /> Drilling Method ❑ Mud Rotary ❑ Air,�,//Rotary F1Auger LiCable Tool ❑ Push Point LIOther <br /> z<lProposed Well Depth_ %ft% Excavation 12— in diameter ❑ Open Bottom1;k-ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter—16� in Thickness/Gauge/ASTM Sched 4' 11Steel clastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑D ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP `Z-. Pump Set C.? 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 /> MI/ " VANCE NOTICE REQUIRED FOR INSPECT!PNS - PLEASE CALL (209) 953- 697 <br /> SIGNED ! /il TITLE � DATE Q <br /> �l <br /> i <br /> cl <br /> 1 'p <br /> 11P 117 <br /> r <br /> AtT L <br /> J � <br /> E <br /> EP RTMENT USE NLY <br /> Application Accepted By Date Z 6AP70 Area Employee ID#���L <br /> Grout Inspection By ' Date ' 4'FJSPECIAL Well Permit <br /> Pump Inspection ByP� Date \l 2h\�� ❑ WAIVER Received <br /> Soil Boring Insection By Date Constructed Well Depth ft <br /> NTS <br /> COMME � D L ,C-_.---if T c?Aj 1ui, /0/h - PAYMENT <br /> PE SC Received ck# Amount Permit/ t(t <br /> Codes Ifo B Cash a ifted Date Service Re uest# Invoice ID# <br /> ko A '' ' 4-' <br /> - <br /> SAN JOAQUIN COUNTY <br /> HEALTH OEPARTMENT <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />