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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 ' 1 DCALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2q�l 7 4 IF ST R.+ �ZV W y —. CITY/ZIP S�Q�G Y� m <br /> JOB ADDRESS M <br /> CROSS STREET APN ZVI 27� PARCEL SIZE ?•.S LAND USE APPLICATIONN/# <br /> OWNER NAME (IU 1�Q �r\4 V�`t g _ PHONE`1 S) /(/f ��V LAf �? <br /> OWNER ADDRESS „2 I-I�1 LC.)1M-A-^ 1Tr _ CITY/STATE/ZIP o1 V� N r 412/- <br /> 7 <br /> CONTRACTOR MCLS tit bt-AiI1\n6 `LKL' PHONE 1:52Z-1 ' _12S <br /> CONTRACTOR ADDRESS I l9 Albtr$ U _ CITY/STATE/ZIP MOJ'e5-] a1 C4 S3 <br /> 3-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 'KC-57 1 I C-61 D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:- eneral Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural CI Industrial Cl Water Quality Monitoring I i Soil Sampling/Characterization <br /> ❑ Public Water System #r•. <br /> If different from Owner: Water System Name Contact Name or Phone <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification Other P <br /> #of borings #of borings <br /> [I Monitoring Well(s) #of wells ❑ Soil Boring(s) I 1 Geotechnical <br /> [IOut-Of-Service Well ❑ Out-Of-Service Well Renewal I i Cross-Connection Rep.$A/V O 2019 <br /> [INew Pum I i Pum Replacement 1-1 Pum Repair Raise Well Casingli A <br /> WELL CONSTRUCTION �ALTy 0 VEIVTAL <br /> Drilling Method XMudRotary i I Air Rotary i i Auger Cable Tool I I Push Point 1.1 Other EPARTNjE <br /> Proposed Well Depth6 ft Excavation 12— in diameter I 1 Open Bottom Gravel Pack/Gravel Size in diameter <br /> i i ConductCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 7 in Thickness/Gauge/ASTM Sched 7,q 0 f i Steel 4VPlastic 1 1 Stainless Steel I i Other <br /> Grout Seal Depth 160 ft (I Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method )ODumped ❑ Free Fall 1 i Other I i Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller XPump Contractor I 1 Other <br /> 11 Concrete Pedestal I(Dimensions:Width ft Length ft Thick in ❑ Christy Box I I Stove Pipe <br /> PUMP ❑ Submersiblef I Turbine I 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 /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INEiPECTIONS - PLEASE CALL (209)`953-7697 <br /> SIGNED �— TI E D ry/Ae~ DATE / <br /> s <br /> o <br /> 0 <br /> Lill <br /> S� Irl k� <br /> NIEL <br /> D5r1PARTMENT USE O N L Y <br /> Application Accepted By Date ( 5� � Area 1 Employee ID# y� <br /> Grout Inspection By J�t�f �\ Date O l (,tD\,`A I ECIAL Well Permit <br /> Pump Inspection By Date 1 1 WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Checkjtj Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted _ ervice Request# <br /> D 0 0 <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />