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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 FXPIR, ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �[ _ CITY/ZIP / m <br /> CROSS STREET E' lL V, APN ;0Y - -1 PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME "0, PHONE �1 O/ ��cJ_ / �✓�' <br /> OWNER ADDRESS ✓ ,/► �' (,f y ' p �/J CITY/STATE/ZIP <br /> CONTRACTOR OU1 YYnOLf 1� I CN1�/► U�1���b d '—�C_(�l1 PHONE / /- <br /> CONTRACTOR ADDRESS '�9/0 CITY/STATE/ZIP v lU a • ' i � <br /> SUBCONTRACTOR 1PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 ❑ D-09 i 1 Other NUMBER q&KV49 EXPIRATION DATE r C;2 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) i Arsenic(4393) <br /> INTENDED USE }(Domestic/Private I Irrigation/Agricultural rI Industrial Water Quality Monitoring 1_I 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 Ll Replacement Well CI Well Alteration/Modification IJ Other <br /> ❑ Monitoring Well(s) #of wells D Soil Boring(s) #of borings 1 Geotechnical #of borings <br /> P Out-Of-Service Well ❑ Out-Of-Service Well Renewal El Cross-Connection Repair <br /> I1 New Pump I XPumpReplacement P PUrnp Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method F1 Mud Rotary 1 Air Rotary I_! Auger 1 Cable Tool Push Point 1 Other <br /> Proposed Well Depth ft Excavation in diameter I i Open Bottom P Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel LI Plastic P Stainless Steel ❑ Other <br /> Grout Seal Depth ft 11Neat Cement(94 Ib bag/.5-10 gal water) 11Sand Cement F&Y=qial water <br /> I1 Bentonite(20%solids) ❑ Other RECEIVED <br /> Grout Placement Method 1 Pumped t I Free Fall P Other I 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Other J° <br /> P Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box <br /> PUMP Submersible❑ Turbine F.1Other HP Pump Set ft Standing Wa$ � .,,(t <br /> . v t r-r-r-o <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 /> Mn11 2 =HDVANCE <br /> NOTICE REQUIRED FOR I PECTIIJO�NS - PLEASE CALL (209)JQ5 -7697 <br /> SIGNED /s'%//� TITLE j��;'%� L DATE C "' <br /> 11 '1114 1 <br /> 5&"PA TMENT U E 0" <br /> LY /� <br /> Application Accepted By Date Area Employee ID# 61r <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By v�� �1�i1Cti .Ctet Date C� Gi /I 11 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> CQc1q,s Info Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />