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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 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / � to <br /> JOB ADDRESS 6 L- 'tom CITY/ZIP � �A m <br /> CROSS STREET API 0 _PARCEL SIZE LAND USE APPLICATION# <br /> cn <br /> OWNER NAME PHONE � l P <br /> OWNER ADDRESS �'d�Ail� CITY/STATE/ZIP 9 <br /> CONTRACTOR VEX_ ��C Z9�4y,11 PHONE <br /> S S <br /> '�? <br /> CONTRACTOR ADDRESS A 2 P CITY/STATE/ZIP <br /> SUBCONTRACTORG�l{ ��5'-� ''-K PHONE 32 - 3 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE ><C-57 CI C-61 11D-09 11Other NUMBER'?/7JC -f EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: !General Mineral/Coliform Bacteria(4391) i Dibromochloropropane(4392) i- Arsenic(4393) <br /> INTENDED USE .R::Oomestic/Private ❑ Irrigation/Agricultural ❑ Industrial [_i 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 replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethocU-B-Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 ZC� ft Excavation in diameter CI Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2V ❑ Steel js Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth 1X� ft 11 Neat Cement(94 Ib bag/5-10 gal water) k5and Cement /11) sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Methods Pumped ❑ Free Fall ❑ Other i I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Xbriller ❑ Pump Contractor LI Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box El Stove Pipe <br /> PUMP <fSubmersibleEl Turbine ❑ Other HP -2— 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 /> MINIMU ,48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697/ <br /> SIGNED TITLEDATE <br /> Al <br /> 0 <br /> N p <br /> UE <br /> A TENIV <br /> V <br /> PARTMENT U E ONLY D, <br /> Application Accepted By Date V Area Employee ID# <br /> r <br /> Grout Inspection By ' Date Z.Lq7 LT <br /> ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspe ion By Date Cons ructed Well Depth ft <br /> COMMENTS 17"e 4 <br /> I <br /> PE SC7 Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> I f/G1 21 Azz 7110/0 <br /> L 1 L1,A C, -7 IU I <br /> IrlZ io q 1n! 3 <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />