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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 EXP ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V su/" CITY/ZIP � T m <br /> �a v <br /> CROSS STREET �'9 APN�/�--1400PARCEL SIZE `/ LAND USE APPLICATION#e�e� / A <br /> OWNER NAME ���� �G i G� PHONE 0 ° U) <br /> OWNER ADDRESS /t L; �TY/STATE/ZIP <br /> CONTRACTOR Y- zz."- PHONE <br /> CONTRACTOR ADDRESS �✓ CITY/STATE/ZIP <br /> SUBCONTRACTOR , r-G�Sc� G PHONE 1 Y S!RC1 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ><6-057 u C-61 I I D-09 i I Other NUMBER -7 EXPIRATION DATE ^� r <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE A<-Domestic/Private I I Irrigation/Agricultural I 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 I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 1-1 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump Pump Replacement I I Pump Repair I I Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Metho&,.�Iud Rotary Air Rotary Li Auger L Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> i_I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel XPlastic ❑ Stainless Steel I I Other <br /> Grout Seal Depth /,)(I ft Ll Neat Cement(94 Ib bag/5-10 gal water) Sand Cement ���. S sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped i I Free Fall ❑ Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By }r-Driller LJ Pump Contracto? ❑ Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in Christy Box i Stove Pipe <br /> PUMP Submersible I Turbine F1 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 VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) ,9153-7697 / <br /> SIGNED L�r� TITLE � G�jj�E rt DATE <br /> G <br /> m, <br /> � N <br /> N / <br /> p Tq <br /> T <br /> r <br /> EPARTMENT US ONLY <br /> Application Accepted ByDate Area Employee ID# <br /> Grout Inspection By Date SPEC AL Well Permit <br /> Pump Inspection By v u Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS L� <br /> PE SC Received QbCAkAP jRemjitted <br /> unt Date Permit/ Invoice# Well ID# <br /> Code Info B Cash Service Request# <br /> I r� 5 <br /> o L I i ' ti W _�Qq7u <br /> 11 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />