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WELL/PUMP PERMIT '' <br /> SV,N JOAQUIN COUNTY ENVIRONMEFff]]AL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON T(!2,-0,9,j,4,68-3420 <br /> NON-REFUNDABLE PERMIT on CA6L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> f` � 7/� cn <br /> JOB ADDRESS ✓ v � d.'- �-v CITY/ZIP c /}rev, ° m <br /> CROSS STREET/Y `� APN 9o2 1-06 PARCEL SIZE ( ,(� <br /> t) LAND USE APPLICATION# A <br /> OWNER NAME/ 1.✓/,7�/"/ PHONE <br /> OWNER ADDRESS {/ASL= / CITY/STATE/ZIP <br /> CONTRACTOR �o�CA ,,r.1)�-� fl.( `� : 1�+� PHONE <br /> CONTRACTOR ADDRESS I J 'cJ CITY/STATE/ZIP 1/1-1-1 <br /> dLL./rj,4i_,La- <br /> f <br /> SUBCONTRACTOR C'r! PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE C-57 C-61 D-09 Other NUMBER � .1 31' EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)1-1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE (Domestic/Private CI Irrigation/Agricultural I' Industrial F1 Water Quality Monitoring i! Soil Sampling/Character <br /> ,Public Water System — • I <br /> If different from Owner. Water System Name Contact Name or Phone Number NtCEI <br /> TYPE OF WORK flew Well I I Replacement Well Ll Well Alteration/Modification I I Other <br /> i-i Monitoring Well(s) #of wells U Soil Boring(s) #of borings Geotechnical �bo n 019 <br /> Out-Of-Service Ofu�ervice WPum Replacement ❑ PumRepair 11 Raise Well Cas <br /> Out-Of-Service <br /> fe Well Renewal ion Repair 6q NVIg4u1N COON <br /> WELL CONSTRUCTION H DE�gRTMENT <br /> Drilling Metho�ud Rotary i i Air Rotary U Auger Cable Tool ❑ Push Point I I Other <br /> Proposed Well Depth 3-LO ft Excavation / L- in diameter U Open Bottom >(Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steellastic I I Stainless Steel I i Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) 1.4cand Cement �J sack mix17 gal water <br /> Bentonite(20%solids) U Other <br /> Grout Placement Method Pumped U Free Fall i Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By +Driller U Pump Contractor I Other <br /> Concrete Pedestal UDimensions:Width__LZ_ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP SiZubmersibleI I Turbine I I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS .APPLICATION AND THAT THE WORK WILI. 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 /> MINIMUM 48 HOVR ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED -'�/CJ^_.�� TITLE 4J A4; DATE Z— <br /> 3 ' <br /> DfEPARTMENT USE ONLY <br /> Application Accepted By t Date ` Area `7 r ` Employee ID# fir( �{ <br /> Grout Inspection By Date 1 L <br /> SPECIAL Well Permit <br /> Pump Inspection By Date �/0 S I ` 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth 3Z ft <br /> COMNiE"!TS <br /> PE SC Recei ed Amount Permit/ <br /> Codes Info h Remitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />