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w <br /> r. <br /> _ 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 CfrY/ZIP <br /> 271� 0 <br /> CROSS STREET RKir APN —6, PARCEL SIZE AND USE APPLICATION# <br /> OWNER NAME �C[W��j PHONE rA <br /> OWNER ADDRESS CITY/STATEMIP (J1 41, 2 /y <br /> CONTRACTOR T� 11� p 1 � �`\ PHONE(2O 1/ _1LP <br /> CONTRACTOR ADDRESS • , ��f�X%V?Qrl IYZe )�_ CITY/STATEILP f <br /> SUBCONTRACTOR /. / - �i R� E' TY"t PHONE rT <br /> SUBCONTRACTOR ADDRESS r�7L /� 'FD/I �- CITY/STATE/ZIP V4. to <br /> 41 <br /> LICENSE V1557 D C-61 V C D-09 D Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 DOmestic/PrIVBte D Irrigation/Agricultural D Industrial D Water Quality Monitoring VSoil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 7 Replacement Well D Well Alteration/Modification D Other <br /> [IMonitoring Well(s) #of wells D Soil Boring(s) #of borings Geotechnical tl of borings <br /> D Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pump D Pump Replacement �]Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION / <br /> Drilling Method ❑Mud Rotary C Air Rotary C Auger ❑Cable Tool L4sh Point C Other <br /> Proposed Well Depth _ft Excavation in diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br /> I7 Condu or Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad i Steel -i Plastic u Stainless Steel u Other <br /> Grout Seal Depth ft pleat Cement(94 lb bag/5-10 gal water) 7 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method,(Pumped C Free Fall D Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller 0 Pump Contractor 7 Other <br /> F1 Concrete Pedestal rDlmensions:Width ft Length ft Thick in F-Christy Box r Stove Pipe <br /> PUMP ❑Submersible?Turbine J Other HP Pump Set It 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 /> MINIRWM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> �. <br /> SIGNED - /1l TITLE � cV1r�t(��` DATE P <br /> k�A� <br /> 1 9p�� <br /> ThrOFp�R COU <br /> N7Y <br /> F//T <br /> "P E N E 91NLY <br /> Application Accepted By ate Area Employee ID#� <br /> Grout Inspection By Date SPECI L Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermiU <br /> Codes Info C sh emitted Date Service Ret # Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />