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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 209 953-7�j697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� t IZ(-1 e CITY/ZIP� � / m <br /> 2tJdC�j a <br /> CROSS STREET �e j/J J7 cS/7� APN L 1 PARCEL SIZE LAND USE APPLILICCATIONN�# / v <br /> OWNER NAME f tr/( ([ /���/�/ T�GLL7fD17 �� PHONE;2(4.'?J X7 7 (Q,J� y <br /> OWNER ADDRESS e0j_-9/1 I 6706GWa TES-DI? Sew/P C22kITY/STATE/ZIP g �i (e-e,/2-1 e5 --// <br /> CONTRACTOR !-�/ " ' �G-1% ///�� PHONE 72 - 2--75 -7 <br /> CONTRACTOR ADDRESS _� JLZLG[/��Y7 ��/ CITY/STATE/ZIP <br /> r—r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 7 �{ <br /> LICENSE (;�C-57 El C-61 0D-09 ❑Other NUMBER EXPIRATION DATE <br /> DoMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name uontact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> ❑Geotechnical <br /> E]Out-Of-Service Well E]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 ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation �Y in diameter ❑Open Bottom AGravel Pack/Gravel Size�/b in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched :!�09 /7 ❑Steel )$►Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 200 ft ❑Neat Cement(94 Ib bag/5-10 gal water) rwfzand Cement `U°.� sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method jo Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level Tk:'y-0 _ 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 4 HOIJR ADVANCE NOTICE REQUIRED FOR <br /> C INSPE TTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE (!Fn ,tep/' DATE �2 ))CJ3 <br /> 64"t <br /> LOCI <br /> D P RTMENT USE ONLY <br /> lqq <br /> Application Accepted By Date Z ZQ�9Area / Employee ID# "� °� <br /> 1 2- �h <br /> Grout Inspection By Date 20/9 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS W� u 2�t ' /OYn %I' r r�Yrt ' h �, I A l <br /> wo <br /> r <br /> PE SC Received Check#/ Amount Permit/ � � <br /> Codes Info B Cash Remitted Date Service Request# Invoice# <br /> b l _R NED <br /> Lf 20 Z-I -I O O3 l 0 <br /> 4 12-12-1 W(9 <br /> COUN <br /> ` ENVIRONMENTAL <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />