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' W <br /> �L�. i�U�F� PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95205-(209)468;R4� <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSI'L <br /> �� .��cui/ T.Ar� <br /> JOB ADDRESS �S'9 00�j LL CITY2IP d�/• /�� ms <br /> CROSS STREET • ��•f�10 APN 0 r/-/1 W v_Q //PARCEL SIZ /^i�J/ LAND USE APPLICATION# <br /> OWNER NAME _ Z1,1,9.I Q�✓ Al 114 �A Iln(.�II�S LCL ONE <br /> U) <br /> OWNER ADDRESS T r d �d G v tai ��—CIY/STATE/LP I'+ :::�I 4 <br /> CONTRACTOR C9 Q.i,0..l-(.✓ y J•/j.T� /1�� ~� PHONE9Y3-Q)` ? <br /> CONTRACTOR ADDRESS -%t.a d Ic'"eu,)' CITY/STATE/ZIP � � l�" a T D., <br /> SUBCONTRACTOR PHONE g <br /> SUBCONTRACTOR ADDRESS_ CITY/STATE/ZIP <br /> LICENSE 7 C-57 - 61 0 D-09 C Other NUMBER EXPIRATION DATE V– <br /> DOMESTIC WELL SAM ING:[2 General Mineral/Coliform Bacteria(4391)❑Dibromochloroprop ne(4392)D Arsenic(4393) <br /> INTENDED USE omestic/Private nigation/Agricultural D Industrial D Water Quality Monitoring I Soil Sampling/Characterization <br /> n ublic Water System <br /> 11 different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well 7 Well Alterstion/Modification 7 Other �1 <br /> # ` <br /> D Monitoring Well(s) #of wells �Soil Boring #of borings s) �Geotechnical of borings <br /> n Out-Of-Service Well ,Out-Of-Service Well Renewal Cross-Connection Repair <br /> U New Pum Pum Replacement D Pum Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary Air Rotary " Auger iii Cable Tool Push Point I' Other <br /> Proposed Well Depth ft Excavation In diameter C Open Bottom D Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_&in Thickness/Gauge/ASTM Schad /&66teel U Plastic ❑Stainless Steel L Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) L Sand Cement sack mW7 gal water <br /> L Bentonite(20%solids) L Other <br /> Grout Placement Method D Pumped C Free Fall C Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By a Driller L Pump Contractor Other <br /> ❑Concrete Pedestal DDimenslons:Width ft Length ft Thick in ❑Christy Box C Stove Pipe <br /> PUMP ubmersible' Turbine n Other HP �,Pump Set ft Standing Water Level 5 ft <br /> 1 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 /> !u"f114';N;15C4FU'!.E; -:i lI ii- .,i4;' :i i E REQUIRED FOR INSPECTa 1CAx<;,: -PLEASE CALL(209)953-7697 ,cJ <br /> SIGNED TITLE DATE y <br /> -41— <br /> _ __ .+44+14 <br /> _ – .– <br /> t/ <br /> ECEIE�T <br /> VEp <br /> Y 2 1019 <br /> AQUI <br /> N RONMENTNLATY <br /> DEPARTMENT <br /> DEP TMY <br /> Application Accepted By Dateate 0A `'' Area p oyee ID#_��� <br /> Grout Inspection By 1� Q to Date :j tXWCIALV#I Permit <br /> Pump Inspection By ; li 1,< Y� �X11v 7 Y P� Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Ch92W Amount Permit/ <br /> Codes Info B ash emitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 rewsed 4A4/16 WELL PERMIT <br />