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R <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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS •L� S +�' CITY/ZIP "�/� m <br /> CROSS STREET U J �I(►l/ //L''� JP N n 'i 2,!V c PARCEL SIZE�L�AND USE APPLICATION# <br /> OWNER NAME O�r (�zi `J� CJ//��f PHONE <br /> OWNER ADDRESS !9n;on P� CITY/STATE/ZIP <br /> CONTRACTOR .YI`y �`� ^�h�' /M+ PHONE .��i �� nl✓ �+ <br /> CONTRACTOR ADDRESSPD J �+ e �tS^ CITY/STATE/ZIP �t/o1 <br /> SUBCONTRACTOR DLJP��= PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE uer,-�7 C-61 D-09 Other NUMBERy ; iJ 63 EXPIRATION DATE ` <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE i Domestic/Private _ Irrigation/Agricultural Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 04hlew Well ❑ Replacement Well I I Well Alteration/Modification Ll Other <br /> I I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pum i Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,,P'Mud Rotary Li Air Rotary Auger a Cable Tool ❑ Push Point I I Other <br /> Proposed Well Depth v"o ft Excavation in diameter ❑ Open Bottom <br /> Gravel Pack/Gravel Size in diameter <br /> Conductt+gr Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 5 in Thickness/Gauge/ASTM Sched`L ,iC Steel W Plastic Stainless Steel Other <br /> Grout Seal Depth uft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement !i% y} sack mix/7 gal water <br /> 11 Bentonite(20%solids) ❑ Other <br /> Grout Placement Method,,KPumped ❑ Free Fall I I Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By <briller H Pump Contractor Other <br /> Concrete Pedestal f(Dimensions:Widthft Length ft Thick in I 1 Christy Box i I Stove Pipe <br /> PUMP {oSubmersiblel I Turbine Other HP_ Q_ 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 /> MINIMUM 4.8LHOOJJR A yV ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> (�L <br /> SIGNED 'rC/^r/cJX L2— TITLE /A L, DATE _ C <br /> E IVED <br /> III NAL <br /> T D P T E T <br /> 1--pi I Z)(f4 <br /> ADE ARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By DatPECIA <br /> e 3� L Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received h Amount Permit/ <br /> Codes fo B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />