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WELL/PUMP PERMIT <br /> SAN'JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON'C�" <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> T� 1CIL e-cO S a n t Vc• CITY/ZIPAcaeo, CA ADDRESS m <br /> CROSS STREET J����n t \-164)CS 0V' APN o Q 3k-I— 075 PARCEL SIZE LAND USE APPLICATION# v <br /> X <br /> OWNER NAME ��M PHOONE n tyir <br /> OWNER ADDRESS �?G(gq I^o U j I61� r IJ(. CITY/STATE/ZIP L Cd 1 , C A C1 <br /> CONTRACTOR 11Q p r, 11 1 PHONEa� 7 7/q <br /> CONTRACTOR ADDRESS p V • 1;0A a ' CITY/STATE/ZIPy/_a 1 T 1 C A C1 5 (G'J2 <br /> ) <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 1_I D-09 ❑ Other NUMBER �� CI EXPIRATION DATE L <br /> DOMESTIC WELL SAMPLING: 11General Mineral/Coliform Bacteria (4391)1 1 Dibromochlorolpropane(4392)❑Arsenic(4393) <br /> INTENDED USE ?k Domestic/Private 1-1 Irrigation/Agricultural I I Industrial I I Water Quality Monitoring 1 Soil Sampling/Characte iQn <br /> LI Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK A New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11 Monitoring Well(s) #of wells LI Soil Boring(s) #of borings I Geotechnical b2iT 2019 <br /> Ll Out-Of-Service Well 11 Out-Of-Service Well Renewal I 1 Cross-Connection Repair SAN J J J <br /> XQ New Pum I Pum Replacement ❑ Pum Repair r) Raise Well CasingE OAQ?IN CO <br /> WELL CONSTRUCTION LTH pEPART�AENr <br /> Drilling Method A Mud Rotary 1 1 Air Rotary ❑ Auger i I Cable Tool n Push Point I Other <br /> Proposed Well Depth J(Go ft Excavation �) in diameter 1 i Open Bottom Gravel Pack/Gravel Size t�4 in diameter <br /> ri Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter '�> in Thickness/Gauge/ASTM Sched 62cc rAW ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth loo ft i 1 Neat Cement(94 lb bag/5-10 gal water) Sand Cement )0•S sack mix/7 gal water <br /> l I Bentonite(20%solids) (I Other <br /> Grout Placement Method )4 Pumped I I Free Fall I I Other I l Retardant/Accelerator(name) <br /> PEDESTAL Installed By ?F.Driller I 1 Pump Contractor I I Other <br /> Concrete Pedestal I IDimensions:Width_'6L_ft Length ft Thick in I.1 Christy Box I1 Stove Pipe <br /> PUMP SubmersibleI I Turbine I I Other HP Pump Set 1 5 ft Standing Water Level l CO 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 /> MINIMVM 48 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS -PLEASE CALL(209)/953-7869 <br /> V <br /> SIGNED L1 TITLE 1 c c DATE <br /> S <br /> IN <br /> 'L <br /> C <br /> S <br /> DE ARTMENT WS O LY <br /> Application Accepted By ` Date Area Employee ID# <br /> Grout Inspection By / nE�o� Date p M Tt( PECIAL Well Permit <br /> Pump Inspection By (X �'agkc r1 Date �1jI I I WAIVER Received <br /> Soil Boring Inpecti n By Date Constructed Well Depth ft <br /> COMMENTS Cy 00 <br /> PE Sc ReceivedChec IP Amount Permit/ <br /> o e Info sh emitted Date Service Request# Invoice# Well ID# <br /> '7312, .I9 c, <br /> L 0 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />