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r <br /> WELL/PUMP PERMIT ;jay U r <br /> AN A UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - I)IIS Jo a <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR <br /> FROM DATE ISSUED <br /> IbCV <br /> JOB ADDRESS /� <br /> CITY/ZIP m <br /> / D <br /> CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# v <br /> CC - <br /> m <br /> m <br /> OWNER NAME PHON` 3 <br /> OWNER ADDRESS CITY/STATE/ZIP /✓ <br /> CONTRACTOR ONE <br /> CONTRACTOR ADDRESS rjw CITY/STATE/ZIP nC/4 ✓OC�� <br /> SUBCONTRACTOR A PHONE /01 <br /> SUBCONTRACT R ADDRESS C ISTATE/ZIP <br /> LICENSE C-57 i I C-61 I I D-09 I I Other NUMBER EXPIRATION DATE - <br /> DOMESTIC WELL SAMPLING: 1.1 General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE omestic/Private L igation/Agricultural Industrial ❑ Water Quality Moni oring Soil Sampling/Characterization <br /> /Characterization <br /> If different from Owner: Wat stem Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well 11 Well Alteration/Modification I Other <br /> I I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings Li Geotechnical #of borings <br /> 1-1 Out-Of-Service W II 1] Out-Of-Service Well Renewal 11 Cross-Connection Repair <br /> I I New Pum Pum Replacement I I Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary I I Air Rotary I Auger I I Cable Tool Il Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel _I Plastic 1_I Stainless Steel Ll Other <br /> Grout Seal Depth ft 1 i Neat Cement(94 Ib bag/5-10 gal water) a Sand Cement sack mix/7 gal water <br /> 1 Bentonite(20%solids) LI Other <br /> Grout Placement Method 1 I Pumped I I Free Fall ❑ Other i I Retardant/Accelerator(name) <br /> PEDESTAL Installed By H Driller 1 I Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal 11 Dimensions:Width ft Length ft Thick in t I Christy Box ❑ Stove Pipe <br /> I it <br /> PUMP Submersible)I 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 /> ftw <br /> AD CE NO ICE REQUIRED F INSPE IONS -PLEASE CALL(209) 9,2-7697 <br /> SIGNED TITLE DATE <br /> r <br /> J q <br /> R <br /> All <br /> W-1 IVY 71 <br /> CN <br /> q T <br /> EPA TMENT U E NLY <br /> Application Accepted By DateO Area Employee ID# <br /> Grout Inspection By Date 11 SPECIAL Well Permit <br /> Pump Inspection By "»4\)I SrA Date bS (II I Z,by\ 1-1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC QRqmLvsd-- (SCAheckV Amount Date Permit/ Invoice# Well ID# <br /> od Info B Cash R mitted Service Request# <br /> r� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />