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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 /> // ' CA aS3�6 m <br /> JOB ADDRESS ,.,W <br /> Jr- ��5��Yl \ ) .. CITY/ZIP�M CICI i m <br /> CROSS STREET �` \S(-)L-le )Q'•iL ��1�PN Z[AOI i� PARCEL SIZE 1LAND USE APPLICATION# 0 <br /> / ^� Q� m <br /> OWNER NAME )C��1I� C H�{C�TC'S �� PHONE L�NNU` <br /> OWNER ADDRESS �5 J 1')C16 \V1 ��) CITY/STATE/ZIP M()�C�C Q , Cit <br /> CONTRACTOR �[)5-�Pr r ] PC.lw1P IS Si,e, PHONE&9) <br /> \ e p <br /> CONTRACTOR ADDRESS 1Q(31'73 '*�/C�.C�(J- 'f'V�• CITY/STATE/ZIP '��'•1�/Y1(A,"I� v <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ❑ C-57 ❑ C-61 ❑ D-09 W-Other NUMBER 1 1 GlC? EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ 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 Li Geotechnical #of borings <br /> ❑ Out-Of-Service Well Ll Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool CI Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <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 ❑ Other F1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 11 Pump Contractor 1 Other <br /> ❑ Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine 11 Other HP Pump Set_Led ey 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 /> MINI rOyDVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697Q <br /> SIGNED G% TITLE c©r+rn gAC V" DATE <br /> d e•� <br /> 'gv <br /> A <br /> - t <br /> ✓O <br /> 4 VIA O O <br /> /Dff- "RTMENT USE 0NL rY� C y4 <br /> Application Accepted By V Date �`r Area �'q�+ee`'L_nployee ID# ��1� <br /> Grout Inspection By ` Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date'W X11 I-1 WAIVER Received <br /> Soil BoringAlns ection By Date Conlstructed Well Depth ft <br /> COMMENTS ,f�441 4 C41tii'!; (4 ��gl r'{9f�� Qr 4d VJZI( >�t'ir►!i <br /> PE SC Receivedec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> 1�3 j71 <br /> I <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />