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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2.ELTON AVENUE-STOCKTON CA 95205 -(209)46"420 <br /> < NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 ^ _N <br /> L <br /> JOB ADDRESS 4 CfS`rYZP & O' A q C Q&- <br /> CROSS STREET A Ora L PI APN � [ � PARCEL SIZE LAND USE APPLICATION# S <br /> OWNERNAME 1Q� n � � U �� PHONE (� w <br /> OWNERADDRESS � ` �T -Q_1r1� A M 14VD CmlSTATErzIP ES C( Q �~ .ti, `(S <br /> CONTRACTOR / ' y tW!cNP Co i1 PHONE O� + L kk 6- <br /> (� <br /> CONTRACTOR ADDRESS Cn I InLe �PfV�� FRA CRY/STATEIZIP T\tka�1sori C Q <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI1'1'/STATE/ZIP <br /> LICENSE l C-57 C-61 I1 D-09 I Other NUMBER S EXPIRATION DATE 2 <br /> DOMESTIC WELL SAMPLING:_i General Mineral/Coliform Bacteria(4391)E Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE )(Domestic/Private 7 IrrigatiorVAgricultural r- Industrial ❑Water Quality Monitoring -1 Soil Sampling/Characterization <br /> L Public Water System <br /> If dderent from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well - Replacement Well ❑Well Afteration/Modification F Other <br /> D Monitoring Wells) #of wells 7 Soil Boring(s) s or borings -1 Geotechnical #of bonngs <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal L Cross-Connection Repair <br /> ew Pump Pump Replacement it Pump Repair F Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L Mud Rotary _Air Rotary I Auger Fl Cable Tool -1 Push Point F Other <br /> Proposed Well Depth ft Excavation in diameter L Open Bottom f".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 F Steel L Plastic l Stainless Steel I Other <br /> Grout Seal Depth It L Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> L Bentonite(20%solids) I_:Other <br /> Grout Placement Method u Pumped u Free Fall L.Other L Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller 'Pump Contractor i Other <br /> r Concrete Pedestal nDimensions:Width ft Length ft Thick in n Christy Box -1 Stove Pipe <br /> PUMP Submersible- Turbine ; Other HP 31 q Pump Set I R 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 /> MI�NIwM'U'M' 24 HOUR ADVANCCEl NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76697 <br /> SIONaL/TVh r O� Q ,/ TITLE DATE <br /> eiv <br /> 2018 <br /> o IV SRO M MCOON <br /> MENTI U E O LY ArTyn pR�^FMTM <br /> f/�) <br /> Application Accepted By Date ys � Area Employee ID#,j!! 7 <br /> Grout Inspection By Date C U SPECIAL Well Permit <br /> Pump Inspection By Date I I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C Amount Date PenniU Invoice# Well ID# <br /> Cods Info Remitted rvice R uest# <br /> EHD 4306 6/01/16 WELL/PUMP PERMIT <br />