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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 /> Q Q rt v gS3o�+ m <br /> JOB ADDRESS \ (�U ��I,N-GY M'T�a± Tl . CITY/ZIP � m <br /> CROSS STREETS,F-,40 J;- OV �// /�/�APN L5S'3 l O b PARCEL SIZE qo.ng LAND USE APPLICATION#I (� C <br /> OWNER NAME 1 On)�f'z1 a 1 1 4Q±o5 PHONE 1 l - 2-b 4 .�7 <br /> p Q 1�-/� C, A <br /> OWNER ADDRESS 1 ► o )Qy, 6� CITY/STATE/ZIPT 1 a r-\J, A 9 �/. 1'7 <br /> CONTRACTOR Q , 1 a Tya �C. (�PHONE BN � - ' 1..�at��2 <br /> CONTRACTOR ADDRESS 1 1 �.Q.�V CITY/STATE/ZIP 1 1 085,5 . C f!II:- -1 ✓ `, �� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT <br /> (Y/STATE/ZIP <br /> LICENSE C-57 I I C-61 D-09 Other NUMBER 2 Y(0e )3 EXPIRATION DATE L ' ,( <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private IIrrigation/Agricultural CI Industrial ❑ Water Quality Monitoring I i 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 L Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> Monitoring Well(s)_— #of wells ❑ Soil Boring(s) #of borings i Geotechnical #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump i Pump Replacement Cl Pump Repair EI Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodXMud Rotary I Air Rotary Ll Auger I Cable Tool LI Push Point ❑ Other <br /> Proposed Well Depth 2430 ft Excavation I!j _ in diameter 1-1 Open Bottom Gravel Pack/Gravel Size*t- in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 8 in Thickness/Gauge/ASTM Sched 51:119-2L I I Steel Plastic I I Stainless Steel 11 Other <br /> Grout Seal Depth ft I I Neat Cement(94 Ib bag/5-10 gal wate/) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I I Other <br /> Grout Placement Method kpumped Free Fall l Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Npump Contractor I1 Other <br /> -I Concrete Pedestal 11Di ensions:Width ft Length ft Thick in 1 Christy Box i Stove Pipe <br /> PUMP I I Submersiblei� 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIREOR INSPECTIONS - PLEASE CALL (209) 953-7697 1 <br /> SIGNED L ITL V . DATE 10-1gnto <br /> -1 <br /> SA V <br /> N / U <br /> T P <br /> DEPARTMENT US ONLY <br /> Application Accepted By Date Area1?G Employee ID# <br /> Grout Inspection By'Akno Date ❑ SPECIAL WCII Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> L/ 1 14 12,9t �7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />