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Plk <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT j� CALL 209 953-7697 FOR INSPECTIONS /�EXPIRES 1 YEAR FROM DATE ISSUED <br /> Pd JOB ADDRESS Z a I IM Tk� L_ '1 CITY/ZIP /V�Gy4e C c N 11533A <br /> m <br /> m <br /> d <br /> CROSS STREET APN (� - I <br /> � � I d PARCEL SIZE �I,q�oLAND USE APPLICATION# o <br /> Sal <br /> OWNER NAME _r wm1/d &b e� �>�oy,n ��I e PHONE �_1 I b/ 614p--i (nrn <br /> OWNER ADDRESS /6 q I/ n�� I I`- CITY/STATE/ZIP r/�*4eey, (q 4 S 33.b <br /> CONTRACTOR M ASt I I L S lI rlffi H 4 �_ �`l� PHO / <br /> NE 6ZZ-�1 '1 Z�/�C <br /> CONTRACTOR ADDRESS l I q l`7� CITY/STATE/ZIP /�/�l,d.-S�D i 1 e, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER G06b(,2Z EXPIRATION DATE Y_3o-2A <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural I i Industrial CI Water Quality Monitoring I Soil Sampling/Characterization <br /> I 1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ><NewWell ❑ Replacement Well ❑ Well Alteration/Modification I Other <br /> I 1 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> Cl Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> I I New Pump 11 Pump Replacement ❑ Pump Repair _ I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'�(Mud Rotary I I Air Rotary I I Auger ❑ Cable Tool ❑ Push Point Other <br /> Proposed Well Depth 2-SO ft Excavation 1 2,11 in diameter I I Open Bottom XGravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched - �y 1 1 Steel Plastic I, Stainless Steel I I Other <br /> Grout Seal Depth /0 0 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br /> XBentoni0%solids) El Other <br /> Grout Placement Method ❑ mped ❑ Free Fall Other IJ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Fl Driller Pump Contractor I I Other <br /> -! Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in i I Christy Box I I Stov�Pip, <br /> PUMP I1 Submersible I 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 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 /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE r) Ile DATE Z-2-2-- I <br /> P <br /> Fri <br /> JO Q INCCLINTy <br /> I NAL <br /> DEP RTMENT U E NLY <br /> Application Accepted By /1 �- Date Area Employee ID#� <br /> Grout Inspection By Date /SI IJ SPECIAL Weli Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Depth ft <br /> COMMENTS -71-003 44 <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Service Re uest# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />