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t , <br /> WELL/PUMP PERMIT <br /> ' SAN JOIN 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 /> 3Ln <br /> CITY/ZIP MQK4tc.a 533:2 m <br /> JOB ADDRESS � <br /> CROSS STREET���T ADPN`�.�.� ,�(-� V��,O PARCEL SIZE 0•I LAND USE APPLICATION# <br /> OWNER NAME OrY1eI 1 V�S pLJC I�I�Y 1 Q 1 //��//��PHONE <br /> OWNER ADDRESS W�ZS �yehN� D CITY/STATE/ZIP Adaitter-o73 / <br /> CONTRACTOR f�►SCItI f DSI 11114( PHONE :5 2-2--1 q 2-25 <br /> CONTRACTOR ADDRESS 9 A 1 61[c CITY/STATE/ZIPQ <br /> T ��1�d1 �A L $35-1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP y ?� <br /> LICENSE C-57 ❑ C-61 ❑ D-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 II 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 1.1 Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethocMud Rotary ❑ Air Rotary U Auger ❑ Cable Tool a Push Point LlOther <br /> Proposed Well Depth 3o a ft Excavation q 11 in diameter I 1 Open Bottom >(Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> 1-.6 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 6-T56 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 50 ft I I Neat Cement(94 Ib bag/5-10 gal water) Sand Cement /6, 3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) F1 Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller U Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal [j Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ 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 M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> � Q <br /> SIGNED TITLE1/C� DATE //_/(J <br /> O N <br /> MN � <br /> D P <br /> IT <br /> EP RTMENT USE qNLY <br /> Application Accepted By Date Area Employee ID#/`IM09 <br /> Grout Inspection By - Date S ❑ SPECIAL Well Permit <br /> Pump Inspection By Date F1 WAIVER Received <br /> Soil Boring Inspection By Bale Constructed Well Depth ft <br /> COMMENTS G�r✓�L 524 e O 5 <br /> PE SC Received eck#I Amount Permit/ <br /> o es I fo B ash emitted Date Service Request# Invoice# Well ID# <br /> S-7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />