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t WELL/PUMP PERMIT <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CAUL 20919/53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM <br /> /DATE <br /> ISSUED <br /> JOB ADDRESSI A n T CITY/ZIP ' 6'N <br /> ' Ar���ff��rr �p.0 rr•--- �yyr <br /> CROSS STREET APN�K�nT�! PARCEL SIZELAND USE APPLICATION# A <br /> OWNER NAME V ///PPHHOO_'NE <br /> OWNER ADDRESS ` CITY/STATE/ZIP 94Y. I n <br /> CONTRACTOR K1p_in .T PHONE'-U-0q) <br /> CONTRACTOR ADDRESS, � AY( A;}"PCxY Ra. CiA4f)(k7 CITY/STATE/ZIPSA�brwwa <br /> ��ff <br /> SUBCONTRACTOR I .IA/ 'nV .N PHONE �'/ra, 41A —/�1�nn <br /> SUBCONTRACTOR ADDRESS 2O. y,P�/�� Or. CITY/STATE/ZIP - 6 <br /> LICENSE WIGG'57 11C-61 C D-09 ElOther NUMBER EXPIRATION DATE <br /> Alga It2a;&— <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring VoOSoil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well 7 Replacement Well D Well Alteration/Modification D Other Is <br /> 0 Monitoring Well(s) #of wells D Soil Boring(s) #of borings Geotechnical Allofborn9s <br /> [I Out-Of-Service Well 7 Out-Of-Service Well Renewal D Cross-Connection Repair 3 <br /> ❑New Pum D Pump Replacement D Pump Repair E Raise Well CasingJ <br /> WELL CONSTRUCTIONS <br /> Drilling Method Aud/Rotary <br /> �. C Air Rotary 7 Auger D Cable Tool C Push Point C Other <br /> Proposed Well Deptha^rW it Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> Conductor Easing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched i Steel -i Plastic D Stainless Steel D Other <br /> Grout Seal Depth ft V/eat Cement(94 Ib bag15-10 gal water) C Sand Cement sack mix/7 gal water <br /> i i Bentonite(�0%solids) i Other <br /> od Pu <br /> Grout Placement Met] mped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By :!Driller D Pump Contractor 7 Other <br /> F1 Concrete Pedestal P01mensions:Width It Length it Thick in F Christy Box r-Stove Pipe <br /> PUMP E Submersible D Turbine 7 Other HP Pump Set ft Standing Water Level it <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 /> MINIWJM 48 HOUR ADVANCE NOTICE REQUIRED FOR <br /> INSPECTIONS-PLEASE CALL(209)953-7697a <br /> SIGNED TITLE �` ��11 «-r DATE I"I-1 <br /> C�4f <br /> ��I <br /> Q, <br /> Nc <br /> ENT <br /> P%_t T M ENT UISE #� <br /> Application Accepted By ,!a ate � Area Employee ID <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date �* 1 WAIVER Received <br /> Soil Boring Inspection By Date J Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> ods In By_ Cash em'ttd Date Se ice Request# Invoice# Well ID# <br /> I <br /> EHD 43-O6 revised 4N4/16 0�/►,Y A111 �& 4 ] 1 WELL/PUMP PERMIT <br />