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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> -�y�1p ^ �j rn <br /> JOB ADDRESS /'� lam? �1 nP,��L� r C iL �h' / CITY/ZIP A,!G )n Po "�SZ D <br /> CROSS STREET rJ A:5—Il 14 y U � APN �5'Z6P 04-/ PARCEL SIZE t/,3 13LAND USE APPLICATION# 0 <br /> OWNER NAME /o PHONE <br /> OWNER ADDRESS w ` L CITY/STATE/ZIP AL/1Z'"P J J Z Zv <br /> CONTRACTOR //Z�� kx--, �,t� - PHONE zz o--3♦VU-7+3-70 <br /> CONTRACTOR ADDRESS "/'O Z— —1r KS's �' CITY/STATE/ZIP LCZO / C4 '!j Z /r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE t�-57 I I C-61 1.1 D-09 ❑ Other NUMBER &gq 0o q EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:i I General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)Ll Arsenic(4393) <br /> INTENDED USE n Domestic/Private (I Irrigation/Agricultural I I Industrial ❑ Water Quality Monitoring X Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I I New Well I I Replacement Well I I Well Alteration/Modification I 1 Other <br /> I) Monitoring Well(s) #of wells Soil Boring(s) ll- #of borings ❑ Geotechnical #of borings <br /> I I Out-Of-Service Well I1 Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> I New Pump I I Pump Replacement rI Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method I I Mud Rotary I I Air Rotary o Auger f I Cable Tool I_I Push Point I I Other <br /> Proposed Well Depth ft Excavation 1 _ in diameter L; Open Bottom IJ 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 I Plastic ❑ Stainless Steel I I Other <br /> Grout Seal Depth 15- ✓ eat Cement(94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> I I Bentonite(20%solids) I I Other <br /> Grout Placement Method I I Pumped Z Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller 1 I Pump Contractor I I Other <br /> 1 i Concrete Pedestal I(Dimensions:Width ft Length ft Thick in ❑ Christy Box IJ Stove Pipe <br /> PUMP [I Submersible I Turbine (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 /> MINIMUM 48 HOUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS -PLEASE CALL (209)95a-7697 C, <br /> SIGNED TLE i.L-f G/ DATE <br /> KF;qt pi <br /> p; 9 <br /> NN <br /> EN I O ME T L <br /> H ( H DE A ENT <br /> EPARTMENT USE O LY <br /> Application Accepted By Date Area Employee ID# � <br /> Grout Inspection By Date I PECIAL Well Permit <br /> Pump Inspection By Date / I I WAIVER Received <br /> Soil Boring Inspection By ADate [ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Seryice Re uest# <br /> 2$ "2 �- <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />