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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 Ln <br /> JOB ADDRESS (f t►�ITY/ZIP PEAZV v m <br /> CROSS STREET /"l lam/ 1*11 T ,6lcV N L,��J�—�7�e �� PARCEL SIZE t�LAND USE APPLICATION# ` I� <br /> cn <br /> OWNER NAME 1 < /' `- J PHOANE' 0O ��+�4�L/ �/ <br /> OWNER ADDRESS - /7( /f �je— <br /> ;7 1-1 /&; WJe STATE/ZIP <br /> CONTRACTOR /�� / /L '% PHONE <br /> CONTRACTOR ADDRESS L —�tL � CITY/STATE/ZIP 'L <br /> SUBCONTRACTOR �— PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP -- <br /> LICENSE 57 'E-61 1 1 D-09 I I Other NUMBER O J EXPIRATION DATE / 5/ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE I Domestic/Private i Irrigation/Agricultural : Industrial Water Quality Monitoring i 1 Soil Sampling/Characterization <br /> 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 ❑ Other <br /> I I Monitoring Well(s) #of wells i I Soil Boring(s) #of borings LI Geotechnical #of borings <br /> ut-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair � �I ®7. <br /> I 1 New Pump I] Pump Replacement I I Pump Repair ❑ Raise Well CasingT <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary Auger I Cable Tool Push Point 1 Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom ii Gravel Pack/Gr" in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ftSALT O/vvIm Nr, <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel ❑ Plastic Stainless Steel 11 <br /> Grout Seal Depth ft I I Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sac ix/7 gal water <br /> I Bentonite(20%solids) I I Other <br /> Grout Placement Method 1_I Pumped Free Fall Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller n Pump Contractor I I Other <br /> ❑ Concrete Pedestal 'Dimensions:Width ft 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 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 /> N/CCE NOTICE REQUIRED FOR/Ij PPE/CATIONS - PLEASE CALL (209) 953-y697 S� <br /> SIGNED / t� %/'f �\ TITLE �L"'/� Vel DATE /L' l <br /> EPA R T M ENT U S E ON LY <br /> Application Accepted By Date Area Employee ID#"-=O <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Waaap Inspection By T��'i� ��)� �di I'V�(u✓ Date �L1 1� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS IL I J <br /> 1 <br /> PE SC Received hec Amount Permit/ <br /> Codes Inf B ash emitted Date Service Re uest# Invoice# Well ID# <br /> EHD4'06 8/01/16 WELL/PUMP PERMIT <br />