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• w <br /> WELLiPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT <br /> , p CALL 209 953-1697 FOR INSPEC'T'IONS EXPIRES 9 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �Yt)�?k ib-- bola- — J4, 1416t)`Q,iys P,irr, CITY/ZIP [ S L <br /> cbje 1�� D� 1� �Z-)00� `733 0 <br /> CROSS STREET �f�c; APN PARCEL SIZE v LAND USE APPLICATION# <br /> OWNER NAME / w y LN L PHONE 1aNnn <br /> OWNER ADDRESS ?10 CITYISTATE/ZIP <br /> YSCONTRACTOR PHONE <br /> CONTRACTOR ADDRESS #-rI4— rN``0rPO .3&e,, /00 ciTY/STATEiZIP -C�OCOpt L gSZO� <br /> SUBCONTRACTOR i C,, <br /> D;rJ I h O' }, PHONE 4> 3 / — k7--?V <br /> -?V <br /> SUBCONTRACTOR ADDRESS ✓13 � �1� P pJ y CITttrrYY�/STATEIZIP s` cra^f-H�W <br /> LICENSE C-57 El C-61 11D-09 ❑ Other NUMBER il� ��' EXPIRATION DATE f ZP ZO <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane (4392)D Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring V1 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #of borings Geotechnical�_#of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement D Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION ,y <br /> Drilling Method Y Mud Rqtary ❑Air Rotary 1u Auger ❑ Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 0 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Piastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft v/Neat Cement(94/b bag15 10 gat water) ❑ Sand Cement sack mW7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method d Pumped ❑ Free Fall ❑ Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Drilier ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal DDimenslons:Width it Length R Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ 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 /> 1 MUM 48 HOUR DVANCE NOTiCE REQUIRED FOR IIN,(�PECTIONS -PLEASE CALL(209)953-T76697 <br /> SIGNED ' TiTLE DATE !/J`7141 <br /> 1 1+ <br /> Q <br /> N <br /> PA TMENT U ENLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date 17 SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received <br /> Soil Boring Inspection ByAIJ <br /> Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service R quest# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />