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WELL/PUMP PERMIT <br /> SA UINI H PARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> A 'ISP CALL 209 53-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �+ �4�7 +t J CITY/ZIP /fit / </ - <br /> CROSS STREET (0/ G. CTL APPO PARCEL SIZE LAND USE APPLICATION# o <br /> m <br /> OWNER NAME is l c� PHONE �� vi <br /> OWNER ADDRESS CITY/STATE/ZIP /, <br /> CONTRACTOR � � rr �L PHONE 7 '" 4e-,7 2-_f <br /> CONTRACTOR ADDRESS CITYISTATE/ZIP <br /> SUBCONTRACTOR )/ PHONE 3 2_7- 311 W <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 6-2-// <br /> LICENSE ><C-57 11C-61 El D-09 ❑ Other NUMBER`S 7/3CTS EXPIRATION DATE Cl—,-/ <br /> DOMESTIC WELL SAMPLING: F-i General Mineral/Coliform Bacteria (4391) i Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE .+domestic/Private ❑ Irrigation/Agricultural ❑ Industrial iJ 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 Xieplacement 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 Method,4ud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 LC3 ft Excavation _� in diameter ❑ 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 '2—V Li Steel )Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Z X� ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method-C Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Xbriller CI Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Widthft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP -?— Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT t 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 <br /> TITLE������` DATE- 10_/�. <br /> r <br /> N jo, <br /> 1 0 M <br /> A ;reN <br /> Nlr <br /> PARTMENT U E ONLY <br /> Application Accepted By Date o Area Employee ID# <br /> Grout Inspection By ' Date ❑ PECIAL W@II Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspe ion By Date Cons ructed Well Depth ft <br /> COMMENTS 77--e 71 1A1 <br /> l <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> wZ 94zz 7110/0 <br /> L-4-cil 11 L q6,1 L 10MW 5q'lq <br /> Z SID W . 3 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />