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r� ' CYo <br /> 44� <br /> a'o _ <br /> ' '9 WELL/PUMP PERMIT <br /> "All JOP.,.IUIN';OUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NUN-REFUND,ABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r — Ln <br /> Jrv3 ADDRESS A/ CITY/ZIP 9sa15 m <br /> :ROSS STREET v/'`""� � i-./--- APN 4e-I V PARCEL SIZE LAND USE APPLICATION# �j A <br /> OWNER NAME /Q/Vl�fi PHONE �—` �'�-�G N <br /> OWNER ADDRESS 71 t ` CITY/STATE/ZIP <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS / CITY/STATE/ZIP <br /> SUBCONTRACTOR � � I S �/L �— PHONE <br /> v <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP Q <br /> LICENSE F-1 C-57 El C-61 El D-09 ❑Other NUMBER /6 EXPIRATION DATE �� U <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)[]Arsenic(4393) <br /> INTENDED USEomestic/Private ❑Irrigation/Agricultural ❑Industrial E]Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK lew Well E]Replacement Well E]Well Alteration/Modification E]Other <br /> /❑Ms #of borings <br /> onitoring Well(s) #of wells E]Soil Boring(s) #of boring <br /> ❑Geotechnical <br /> F-1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> jklIew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRL06TION <br /> Drilling Methoud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other 19 <br /> Proposed We DepthZSC-) ft Excavation in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 4--'*,4 CGU ❑Steel J&lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) /❑_Sand Cement sack mix/7 gal water <br /> entonite(20%solids) ❑Other <br /> Grout Place nt Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> El Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CEATIFY 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 HO ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953 76 <br /> SIGNED s TITLE �/� DATE <br /> i <br /> a <br /> > c <br /> J <br /> O , <br /> h <br /> s6 <br /> DE ARTMENT USE ONLY <br /> c <br /> Application Accepted By Date Area_ Employee 04T""' <br /> o . 1.p �.z ��` SPECIAL Well P.- <br /> .•r•........ _ f F-- -�f r Date : > 1 ..rtTiit <br /> Pump Inspection By f � , .; Date_ t u C^r". ." ' Rpcai`,YEd <br /> i f � <br /> Soil Boring I spection B Date I Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> -17 <br /> hk� <br /> =06-8/01/16 / WELL/PUMP PERMIT <br />