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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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSKI P-01 CITY/ZIP Sal m <br /> CROSS STREET �^ Y APN PARCEL SIZE LAND USE APPLICATION# !' 0 <br /> OWNER NAME PHONEO�_IOC> l7"f&6D m <br /> m <br /> fc <br /> OWNER ADDRESS CITY/STATE/ZIP V 69 <br /> CONTRACTOR HONE `��V�yq�� !/33 l/-3, <br /> CONTRACTOR ADDRESS `1 � 1 V ` /cly l Wd(i'l CITY/STATE/ZIP V �V �// .LI-7 <br /> SUBCONTRACTOR X Z 4 PHONE <br /> SUBCONTRACTOR ADDRESS 42&1(' <br /> /STATE/ZIP <br /> LICENSE C-57 11C-61 ❑ D-09 11 Other NUMBEREXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE Domestic/Private CI Irrigation/Agricultural ❑ Industrial 11 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 ❑ Soil Boring(s) #of borings l Geotechnical I—AfIN. <br /> N <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection RepairV <br /> ❑ New Pum 11 Pump Replacement Pum Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION Our 1 9 <br /> Drilling Method Li Mud Rotary 11 Air Rotary ❑ Auger ❑ Cable Tool Ll Push Point 11 Other SAN �__ � ?018 <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gra vji UIR�./�1�ir2meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft CTy0EpgRTTAC 4K <br /> Y <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 1-1 Stainless Steel ❑ Other MENT <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall LI Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe�] <br /> PUMP 1 Submersible[] Turbine ❑ 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 /> WORK S.COMPENSATION LAWS. <br /> U 4 C OTICE REQUIRED F INSP TIONS -PLEASE CALL (209) 5 1769 <br /> SIGNED TITLE DATE,0I 4A1 <br /> !� <br /> l <br /> EF RTMENT USE ONL Y <br /> Application Accepted By / c Date Area Employee ID#j�_ <br /> Grout Inspection By n Date ` F1 SPECIAL Well Permit <br /> Pump Inspection By W'Ntt );J 1�b�)`1��1��1�rl��,N Date K F1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as emitted Service Re uest# <br /> cSB t a(` <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />