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r, WELL/PUMP PERMIT <br /> SAN JOA,I.:N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 9J53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS 43 8-7:72-aGCITY/ZIP G/ f; �4f m <br /> 9s <br /> d ! n <br /> CROSS STREET We54 R\ate► APN7 <br /> PARCEL SIZE LAND USEuAPPLICATION# <br /> OWNER NAME Mi e,h A-C gel!„-Cr PHONE i )4IC- 'q 91 <br /> -2aqc � <br /> OWNER ADDRESS 6(4 1 A YEA f4ty S T Df CITY/STATE/ZIP Ihn ,ca S &6�� <br /> CONTRACTOR MAsell ii I p1y�o I l'hnn� �' �APHONE"222-- -`2-S S <br /> CONTRACTOR ADDRESS 1 1-1 /� ILK rS Ra CITY/STATE/ZIP/Y,Oj`PS j f <br /> s <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP t( <br /> LICENSE C-57 I7 C-61 I I D-09 I I Other NUMBER 42wG27, EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural F1 Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I” Public Water System <br /> JDA A-- <br /> If different from Owner: Water System Name Contact Name or Phone Nu e <br /> TYPE OF WORK ' New Well Replacement Well [IWell Alteration/Modification i Other <br /> I; Monitoring Well ❑ g #of borings � <br /> Well(s) #of wells Soil Boring(s) Geotechnical l�/ei ., <br /> I' Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair —I#of borin� <br /> / ?®,�Q <br /> 1 New Pump I Pump Replacement ❑ Pump Repair s Raise Well CasingJO <br /> WELL CONSTRUCTION lyE�AtT/RONMF OUNTY <br /> Drilling MethodyMud Rotary I I Air Rotary Auger I1 Cable Tool 11 Push Point 1.1 Other N D' ARrA NTAL <br /> l <br /> Proposed Well Depth >60 ft Excavation �Z 1 in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter �6 in Thickness/Gauge/ASTM Sched 200 ❑ Steel lastic I-1 Stainless Steel I I Other <br /> Grout Seal Depth 200 ft i I Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method)(Pumped ❑ Free Fall F! Other LI Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor 1 Other <br /> Concrete Pedestal ED ons:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP i I Submersibles 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 /> MI M 48 HOUR ADVANCE NQILQEREQUIRED FOR (INSPECTIONS - PLEASE CALL (209) 953--7697 <br /> SIGNED TITLE Dr`►I I e e- DATE ZG <br /> •r, C <br /> r <br /> PDoEPA,,RTMENT USE ONLY <br /> Application Accepted By Date ( - Area Employee ID <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date _I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Code Info By Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />