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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 136-11 W IM-C 4- RA CITY/ZIP 1_/-qdYh; ret 7540 m <br /> CROSS STREET Ovo I��,1,y1.)_ �Q• APN l)h_j-21pO -0-70 PARCEL SIZE 69.S LAND USE APPPLICATIIONN# A <br /> OWNER NAME V SP t�dll t/0 Lc— PHONE/ q86-/8' 4 Cn <br /> ��^ C? <br /> OWNER ADDRESS '3S0 Col, L--A--- AL)f S4j. ISO CITY/STATE/ZIP Pd� J7 i 64 ` iW/O <br /> CONTRACTOR Mase`ISS u_ r1f_- PHONE 1 / <br /> J� I-qZ8 <br /> CONTRACTOR ADDRESS Ib�f S ILOI CITY/STATE/ZIP /M' I6d,-�T O I L e4 7 S.?`-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ><C-57 II C-61 l D-09 II Other NUMBER EXPIRATION DATE �`•�V� 2 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural 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 El Replacement Well ❑ Well Alteration/Modification I I Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 11 New Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodyMud Rotary ❑ Air Rotary I 1 Auger I. Cable Tool ❑ Push Point i Other <br /> i <br /> Proposed Well Depth 0 0 ft Excavation �v in diameter f 1 Open Bottom Gravel Pack/Gravel Siz in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter jZin Thickness/Gauge/ASTM Sched 6•2-1!;7u Steel Plastic I I Stainless Steel 11 Other <br /> Grout Seal Depth so ft I I Neat Cement(94/b bay/5-10 gal water) x Sand Cement sack mix/7 gal water <br /> 'I Bentonite(20%solids) D Other <br /> Grout Placement Method Mumped n Free Fall CI Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 11 Pump Contractor I I Other <br /> .1 Concrete Pedestal L-1 Dimensions:Width ft Length ft Thick in I Christy Box I I Stove Pipe <br /> PUMP Il Submersible 11 Turbine 1 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE '(D DATE DATE 50-r <br /> Ll <br /> HIEi <br /> q <br /> N U/ <br /> D N <br /> T <br /> D.EjPA TMENT UV EqNLY <br /> Application Accepted By Date 2-1/ l Area EmployeeID <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes 1pto By Cash Remitted Service Request# <br /> V <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />