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WELL/PUMP PERMIT 201101 <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE• '\ <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXF J <br /> n C N <br /> JOB ADDRESS �V �J �(-De A1117 1lL' CITY/ZIP �� m <br /> CROSS STREET Alke APN PARCEL SIZE LANE �j I��nV n <br /> r OWNER NAME tinn t:_I��°'I U`1 VI _ PH( V0—l VAC�✓ m <br /> ALDCP- AVE <br /> 11-1 <br /> OWNER ADDRESS CITY/$TATE/ZIP <br /> CONTRACTOR c 4G ✓ kACwt, D T PHONE �NO <br /> 1 <br /> 0 � <br /> CONTRACTOR ADDRESS 6A Clede CITY/STATE/ZIP t-11V'rW10-tp' <br /> SUBCONTRACTOR M PHONE/LZ <br /> SUBCONTRACTOR ADDRESS A0 CITY/STATE/ZIP_ 'Alm <br /> LICENSE C-57 I I C-61 LI D-09 I I Other NUMBER / 7 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Li Domestic/Private Irrigation/Agricultural 11 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 I I Other <br /> I I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> F Out-Of-Service Well ❑ Out-Of-Service Well Renewal C Cross-Connection Repair <br /> New Pump Pump Replacement ❑ Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION Z�t <br /> Drilling MethodXMud Rotary Air Rotary 11 Auger ❑ Cable Tool Fi Push Point J Other <br /> Proposed Well Depth /�ft Excavation AZ in diameter i_1 Open Bottom AGravel Pack/Gravel Size , cr in diameter <br /> Cl Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Tgickness/Gauge/ASTM Sched 4Steel ❑ Plastic I I Stainless Steel 11 Other <br /> Grout Seal Deptht ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement i sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement MethodwkPumped ❑ Free Fall I Other I1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 'Pump Contractor i l Other <br /> I Concrete Pedestal I(Dimensions:Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br /> PUMP LI Submersible❑ Turbine I 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 /> MI IMU 48 lH0)A_ADVANqE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNE TITLE �%L✓ '� DATE /y <br /> Vj:)A(;ijjlV <br /> LT /vE <br /> R � <br /> D PAR ,MENT USE ONLY <br /> Application Accepted By Date ! �� Area Employee ID# <br /> Grout Inspection BX Q Date Ld ! ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3•wt2ft <br /> COMMENTS 4 t / / -' vl� <br /> Pff SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re ue t# <br /> ! " � � I <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />