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WELL/PUMP PERMIT <br /> SAN JOAO,IIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT —^� CALL 209 953-7`6'9.7 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> /el// !�L T�� 'a'�4 � /tel CITY/ZIP �%4 %J�/� m <br /> JOB ADDRESS �CE��[- i m <br /> r... t <br /> CROSS STREET �• / ,J��/T� � APNN� 'e!j l 13 PARCEL SIZE —CLAND USE APPLICATION# QQQ <br /> OWNER NAME ,C/�L` ,LSC L" ���y QC/�<�L' PHONE ;?9* - �l✓U® <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR /( x'/17 PHONE ,Al /!Z <br /> CONTRACTOR ADDRESS �C!'/ CITY/STATE/ZIP <br /> c irk <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATES/ZIP 1 <br /> LICENSE *--57 ❑C-61 ❑D-09 ❑Other NUMBER XY 7,/)/g EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private )grrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name Gontact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification L]Other <br /> #of borings #of borings <br /> Ll Monitoring Well(s) #of wells E]Soil Boring(s) ❑Geotechnical <br /> ❑Out-Of-Service Well Ll Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> []New Pum ❑Pump Replacement [:]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method $Mud Rotary [J Air Rotary ❑Auger [-]CableTool F]Push Point ❑ Other <br /> Proposed Well Depth 3&0 ft Excavation / 7�12- in diameter E]Open Bottom [RGravel Pack/Gravel Sized in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Zj�L in Thickness/Gauge/ASTM Sched 2/ ❑Steel 'Plastic L1 Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gat water) 'Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method JX Pumped ❑Free Fall El Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ 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 /> M�Nl #HOUR ADV NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED � TITLE �jC'. %lift � DATE <br /> J <br /> 44 a <br /> Y;l <br /> -. <br /> E V R N N <br /> D P R E T <br /> �__D-E-PARTMENT USE 9NLYI <br /> Application Accepted By Date AreaJEmployee ID# <br /> Grout Inspection By Date' `'SPECIAL Well Permit <br /> Pump Inspection By J Date ❑ WAIVER Received <br /> Soil Boring l7ns ByDa onstructed Well Depth ft <br /> CO�MMEN�TS�� J <br /> Tye �- <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 ,.i I �.` ,' t ' -�('`- VJ�LL/PUMP PER <br />