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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 EXPjj ES 1 YEAR FROM <br /> L DATE ISSUED <br /> JOB ADDRESS r �� <br /> mZ <br /> D <br /> CROSS STREET -1 _.t APN /Z PARCEL SIZE �5 LAND USE APPLICATION#mss//� 0 <br /> OWNER NAME -��/)A /r "In i' `'� PHONE <br /> OWNER ADDRESS A,; LqCITY/STATE/ZIP <br /> /> ? <br /> CONTRACTOR 8 - �^���C= C�I�✓ PHONE J-%/ `2— <br /> CONTRACTOR ADDRESS / CITY/STATE/ZIP C/J/ciZ1�rGi�=L� 4 <br /> SUBCONTRACTOR 'S ��G��c.� � PHONE N <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> �9 / <br /> LICENSE )<557LlC-61 F1 D-09 ❑ Other NUMBER"'T �i EXPIRATION DATE L <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural I 1 Industrial I I Water Quality Monitoring 11 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 [I Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings [I Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump LI Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method`. ud Rotary I I Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> (Proposed Well Depth In ft Excavation in diameter ❑ Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> _1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 7 JtD r I Steel ><P' lastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth %,�l} ft El Neat Cement(94 Ib bag/5-10 gal water) >4and Cement ;�, ,`. sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other_ <br /> Grout Placement Method!00Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By W—Driller [I Pump Contractors, l I Other <br /> 11 Concrete Pedestal ❑Dimensions:Width ft Length ft Thick ) in F1 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 /> MINIMUM 48 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED !` a +Ltn TITLE LL/ i�y't - DATE <br /> rr— <br /> G <br /> � N <br /> in- <br /> N / N <br /> L'EPVP Tq <br /> r <br /> I I P11 <br /> .5 <br /> EPARTMENT US ONLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date SPEC AL Well Permit <br /> Pump Inspection By , S r '.a Date ���/�VJ1C El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedAmount Date Permit/ Invoice# Well ID# <br /> Co eg Info B Cash Remitted Service Request# <br /> �1 11 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />