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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 ./2209 953-7_69 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r J �I'[z C'J CITY/ZIP m <br /> JOB ADDRESS ���`��!Y✓� <br /> CROSS STREET 11/'1G/ /APIN Ill) PARCEL SIZE 1 LAND USE APPLICATION# p <br /> Cn <br /> OWNER NAME Asa PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP 2y <br /> CONTRACTOR /�i') /�S yL /�"1p PHONE 13 1/" <br /> CONTRACTOR ADDRESS <br /> I� 'S `-.2 i CITY/STATE/ZIP <br /> SUBCONTRACTOR lJ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �-57 ❑ C-61 11 D-09 I_I Other NUMBED 7 7 EXPIRATION DATE `= <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria (4391) ibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/ rivate ❑ 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 I>ew Well 11 Replacement Well ❑ Well Alteration/Modification I Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical #of borings <br /> 11 Out-Of-Service Well ❑ Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> ew Pump I I Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method-<MUd Rotary I I Air Rotary ❑ Auger Il Cable Tool I1 Push Point I Other <br /> Proposed Well Depthft Excavation ?` in diameter FI Open Bottom 1'-Gravel Pack/Gravel Size in diameter <br /> [_i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C in Thickness/Gauge/ASTM Sched _L-Z10 I I Steel XPlastic I I Stainless Steel Other <br /> Grout Seal Depth !IX7 ft I I Neat Cement(94 lb bag/5-10 gal water) Land Cement sack mix/7 gal water <br /> Bentonite(20%solids) 1_' Other <br /> Grout Placement MethodA'<Pumped ! Free Fall I I Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By rifler Pump Contractor I Other <br /> F1 Concrete Pedestal Dimensions:Width ft Length ft Thick in I Christy Box Stove Pipe <br /> PUMP .01,Zubmersiblel I Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED /!•L. TITLE Lj�`�7c DATE L� <br /> 2 <br /> AL <br /> S N a n <br /> P T E ? <br /> Dff 'ARTMENT USE ONLY <br /> Application Accepted By Dat Area L Employee ID# <br /> Grout Inspection By Date S' / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspction By Date Constructed Well Depth ft <br /> COMMENTS Al Jjs.t 2 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 2 ---Y "4 <br /> t 3� IL <br /> 1 <br /> 1 <br /> r. <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />