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WELL/PUMP PERMIT <br /> S t.N 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 /> 3b� IJ . i>,k o6 n .l S+b�A. CA 9521.5 M <br /> JOB ADDRESS CITY/ZIP / m <br /> j > (/ <br /> CROSS STREET () Qro D I ,v APN /O1-L36 -V 1.40 PARCEL SIZE f` `y LAND USE APPLICATION# 0 <br /> OWNER NAME ^„„�✓� C�t�4-A PHONE q5-7- 1547 �y N <br /> OWNER ADDRESS IVZ II4QtF,Kej�rlrV^L.+ ��. CITY/STATE/ZIP �7 OGKTCq za <br /> CONTRACTOR •• `MI 1 Y 4_1 JMl• p A PHONE <br /> 1.7 /+ C�Q '�'') <br /> CONTRACTOR ADDRESS 1 l 1 Al�C�� {�-4 CITY/STATE/ZIP/0/J 'e�TD ( 1 7 J / <br /> s <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESSjj CITY/STATE/ZIP <br /> LICENSE C-57 Fl C-61 1-1 D-09 Ll Other NUMBER Y0%2-� EXPIRATION DATE 7`� � 2_1 <br /> DOMESTIC WEL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1 Soil Sampling/Charac�jj � <br /> I Public Water System "x'11 <br /> If different from Owner: Water System Name Contact Name or Phone Numb <br /> d# <br /> TYPE OF WORK IvNew Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> [I Monitoring Well(s) #of wells ❑ Soil Boring #of borings os) I I Geotechnical bo ing? g0j <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 'q V OAQUlN <br /> ❑ New Pum I I Pum Replacement 11 Pump Repair ❑ Raise Well CasingENV/R COON <br /> WELL CONSTRUCTION DEPART L <br /> Drilling Method X Mud Rotary I I Air Rotary I I Auger I Cable Tool i I Push Point I; Other MENT <br /> Proposed Well DepthScz> ft Excavation ._t—2- in diameter ❑ 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 L.50 ❑ Steel Plastic I I Stainless Steel I I Other <br /> Grout Seal Depth ZQD ft I I Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> Ben ite(20%solids) 11 Other <br /> Grout Placement Method umped El Free Fall I i Other j I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor I I Other <br /> I I Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in I I Christy Box 1 Stove Pipe <br /> PUMP ❑ Submersible! Turbine 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 /> MINIM M 48 HOUR ADVAN E NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE e E <br /> o <br /> AN <br /> Q <br /> S <br /> i <br /> y DEPARTMENT USE NLY <br /> Application Accepted By C s� Date ' Area 4 Employee ID#D� t <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By tw Date 1I WAIVER Received <br /> Soil Boring Inspection By Date \\ Constructed Well Depth ft <br /> COMMENTS rUle4 ti clivi'j Cr' t Z ItC <br /> PE Sc Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> 11 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />