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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 E PIRES11'YEAR FROM DATE ISSUED <br /> JOB ADDRESS '� CITY/ZIP / ._A. (`� `� m <br /> CROSS STREET I.�i �% ���' 'r`i APN ©�l V 7U (/��PARCEL SIZE •D t7 LAND USE APPLICATION# A <br /> OWNER NAME C_ `� � PHONE,?/ -t-s-6 z— ����7 m <br /> OWNER ADDRESS �^ 0 ax 3 CITY/STATE/ZIP <br /> CONTRACTOR O /"��u PHONE <br /> CONTRACTOR ADDRESS �� /LJS//��1 / CITY/STATE/ZIP <br /> SUBCONTRACTOR (illy L`/2 � PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LL <br /> LICENSE je C-57 C-61 1 D-09 [I Other NUMBER .1 i EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE y fbomestic/Private ❑ Irrigation/Agricultural I_I Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number PA Vla. <br /> TYPE OF WORK>New Well I I Replacement Well I I Well Alteration/Modification 11 Other <br /> I I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings ❑ Geotechnical <br /> 11 Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair ,"' <br /> 3 2019 <br /> ew Pump ❑ Pump Replacement f Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION JOAQU/ <br /> Drilling Method >Vud Rotary ❑ Air Rotary - Auger Cable Tool ❑ Push Point i 1 Other yE4L, Q M�PpQ� N <br /> Proposed Well Depth v ft Excavation _ in diameter Open Bottom Gravel Pack/Gravel Size If'f M6" <br /> Conductor Casing in diameter ( Conduct�orr Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2�cSteel XPlastic Stainless Steel I I Other <br /> Grout Seal Depth Z wL ft ❑ Neat Cement(94 Ib bag/5-10 gal water) XS and Cement sack mix17 gal water <br /> I i Bentonite(20%solids) ❑ Other <br /> Grout Placement Method,ierPumpecl I I Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By .0-'Driller i 1 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal 'Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP ❑ Submersible) Turbine Other HIP_: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 /> MI UM 48 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> C <br /> SIGNED i��X;2= TITLE L! �[//ti G ,^ DATE <br /> —� <br /> r <br /> v <br /> l <br /> f <br /> n - <br /> I <br /> - PA TMENT USE ) NLY <br /> 7Application Accepted By Date ( Area `Z Employee ID# <br /> Grout Inspection By C to `' ❑ PECIAL Well <br /> C' Permit <br /> Pump Inspection By �/ _iLlate ❑ WAIVER Received <br /> Soil Boring Inspection By Date Copstructed Well Depth �_' ft <br /> COMMENTS <br /> PE SC Received Ch Amount Permit/Code Info —By, Cash emitted Date Service Request# Invoice# Well ID# <br /> co 35 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />