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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 /> JOB ADDRESS 24 y 7 IJ11R� C+ r CITY/ZIP A(C4M J?yi Ca <br /> _ D <br /> CROSS STREET a Ih HV,' APN 06.1-4a0-331 PARCEL SIZE S•3S LAND USE APPLICATION# rn <br /> '7 <br /> OWNER NAME ��A``` �/ �T PHONrE J )61 L'7 In <br /> OWNER ADDRESS •� �al+ I 2-0 CITY/STATE/ZIP 6Gt 1.T ('of I 9��� <br /> CONTRACTOR -elft ..-.��.II VL. .�JPHONE 52-2—le <br /> CONTRACTOR ADDRESS119 e r U. y� <br /> . CITY/STATE/ZIP.(Y r�T ST U. / Co. 1?5-351 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP'+<C-57 <br /> q <br /> LICENSE + C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE �"'t <br /> DOMESTIC WELL SAMPLING!❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural D Industrial ❑Water Quality Monitoring -❑Soil Sampling/Characterization <br /> ❑-Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑Well Alteration/Modification ❑Other <br /> Cl Monitoring Well(s) #of wells '❑Soil Boring(s) #of bonngs D Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pum ❑Pump Replacement ❑ Pump Repair D Raise Well Casing <br /> WELL CONSTRU(;TION <br /> Drilling Method VMud Rotary ❑Air Rotary 0 Auger ❑Cable Tool 11 Push Point: ❑ Other <br /> Proposed Well Depth I ft Excavation in diameter ❑Open Bottom D Gravel Pack/Gravel Size _yi diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-�, in ,Thickness/Gauge/ASTM Sched 1� D Steel Qlastic D Stainless Steel ❑'Other <br /> Grout Seal Depth e)C.) It ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> -XBentonite(20%solids) D Other <br /> Grout Placement Method Pumped D Free Fall D Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> ❑Concrete Pedestal DDimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible0 Turbine ❑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 /> NU=UM 48 HOUR ADVANCE NOTICE REQUIRED FOIR�INSPECTIONS-PLEASE CALL(209/)953-7697 <br /> 6 <br /> SIGNED -'-"""'�^" TITLE ISN(��P DATE 6,1641 <br /> AA <br /> J <br /> ;ILTLORS; Nry <br /> A <br /> JN <br /> YYRMENT/ US O �7LYp I II <br /> Application Accepted By Date fJ GQ I Area_` Employee ID# <br /> Grout Inspection By WZDate ❑ SPECIAL 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 Ch I Amount Permit/ <br /> Code Info B Cash Remitted Date Service RoqueSt# Invoice# Well ID# <br /> Q ++ 3��� � I► q <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />