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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 CALLS 2-09 953-7697 FOR INSPECTIONS <br /> EXPIRES 1 YEAR <br /> FROM DAITE ISSUED <br /> 4� <br /> ItiDA/ <br /> � Mir <br /> CROSS STREEET �L 1'(C11APN PARCEL SIZE/71 LAND USE' <br /> APPLICATION# mLL & n�,' PHONE �Ct (3 CiZ C;C)� <br /> OWNER NAM <br /> vi <br /> OWNER ADDRESS I�� l`\' I\V '• l�lJ CITY/STATE/ZIP_V�C,�� l ''r <br /> CONTRACTOR �d C1 II-c'7 V C \\\ I h�� PHONE �(j,'`I — �?-77 9 <br /> CONTRACTOR ADDRESS �,C I C'AJC `"I CITY/STATE/ZIP Vc 14 I A <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITtYIST((A))TE/LP <br /> LICENSE A C-57 � �I'1 i C-61 I D-09 I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name ContaQ Name or Phone Number <br /> I I <br /> TYPE OF WORK /,New Well _.Replacement Well Well Aheration/Modification Other <br /> I Monitoring Well(s) #of wells ❑Soil Bonng(s) #or honngs i Geotechnical #of borings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pump Pump Re lacemenI �]Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)-W.d Rotary Air Rotary Auger Cable Tool G Push Point Other <br /> Proposed Well Depth ft Excavation_�in diameter i7 Open Bottom >,Gravel Pack/Gravel Size t��- in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTMSched C`22Ci' n,Steel %Plastic I Stainless Steel I Other <br /> Grout Seal Depth C C ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement ( -S sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> r-rmrt ft!nemnnf MoLhcd� P---M,—td n Froo F2II Cthcr /namt) <br /> PEDESTAL Installed By -Driller Pump Contractor - Other <br /> Concrete edestal Dimensions:Width�ft Length ft Thick n Christy Box _:Stove Pipe <br /> PUMP )(\Submersible I Turbine 1 Other HP Pump Set _ft Standing Water Level_ft <br /> 1 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 �J <br /> WORKERS COMPENSATION LAWS. \ I <br /> MINIMUM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 W <br /> SIGNED '�j Com/ � TITLES I &n+ DATE <br /> 5 <br /> I� <br /> V1C <br /> L <br /> U <br /> r I <br /> ECE EST <br /> < jv <br /> ($14)a 1 11 1 1 1 �-Fjtj 1 11 11 111 111 111P 13 2018 <br /> ��. <br /> DEPARTMENT U S E NIL Y HE <br /> i EN14 WUIN nOTUIV <br /> Ty <br /> Application Accepted By L Date f �'� Area Employee ID# STH DEpgRrMENT <br /> Grout Inspection By c1 Date SPECIAL Well Permit <br /> Pump Inspection By <br /> ate V WAIVER Received <br /> Soil Borinq_Inspection BY Date Constructed Well Depth ft <br /> COMMENTS ,") e6 p(h 02 S )(/5f1-,j li <br /> ��Y lIIvl7tTr�n ►tlfA�},� • Ls=-�1c.I� �.��FJr>vc( � � c- �$Sr�JA/Ir��%��( <br /> PE SC Received Check#/ Amount PerrniU ^ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> ( O ( ltDU f .Pff <br /> ASO C-5 i O <br /> EHD 43-06 revised 4/14116 WELL 111.1 PERMIT <br />