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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 ADDRESS L'\. ( CITY/ZIPY m <br /> _ _ ✓ D <br /> CROSS STREET APN I ���� �IPARCEL SIZE LAND USE APPLICATION# 0 <br /> OWNER NAME G1 �� r f o /PHONE <br /> CT <br /> OWNER ADDRESS �\ ( � i \ L�I CITY/STATE/ZIP �G I C tV <br /> CONTRACTOR �L� ^) 1 1 1 PHONE ayiL <br /> / ./I <br /> CONTRACTOR ADDRESS 1`-ll � - I �L� CITY/STATE/ZIP t I�r t r k"L <br /> SUBCONTRACTOR �nT(s 1 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE IC-57 I C-61 D-09 Other NUMBER I of EXPIRATION DATE <br /> DOMESTIC ALL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private [.] Irrigation/Agricultural Industrial I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> Ll Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1�New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> #of borings o <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) i-: Geotechnical 71 <br /> Li Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair CC1VC® <br /> LI New Pum Pum Replacement 11 Pump Repair ❑ Raise Well CasingC <br /> WELL CONSTRUCTION Hl' 0 8 ?019 <br /> Drilling Method >1Mud Rotary^ Air Rotary H Auger Ll Cable Tool [IPush Point ❑ Other SAN-t,,,._ <br /> tv <br /> Proposed Well Depth �1`: ft Excavation _ in diameter n Open Bottom ' Gravel Pack/Gr'wt� CO(llpTVmeter <br /> I Conducto Casing in diameter / Conductor Casing Depth ft TH�EPARR AL <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel XPlastic Il Stainless Steel Other <br /> Grout Seal DepthT� ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> 7Q Bentonite(20%solids) ❑ Other <br /> Grout Placement Method NPumped I I Free Fall Other i I Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller [I Pump Contractor Other <br /> ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box 1 Stove Pipe <br /> PUMP ❑ SubmersibleTurbine 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 COMP SAT]ON LAWS. <br /> MINI M R A E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697/ <br /> SIGNED TITLE l�Y I I'�'I DATE <br /> rl E P 1A R T 14 E !.1 T U/3 E N L Y <br /> Application Accepted By Date Welt Area Employee ID <br /> Grout Inspection By j)�1f�N �l( % � � �) Date `s f(`) l��� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspectio By Date Constructed Well/Depth 7 ft <br /> COMMENTS����4-r / l i' r �;�l — I (L. rt•- Jl—1 D ZZ— <br /> PE <br /> PE SC Received Check#/ ` Amount Permit/ <br /> Codes fo ash emitted Date Service Re uest# Invoice# Well ID# <br /> SD>v -t°I 3 a <br /> Z <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />