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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 /> 1 //���- Ln <br /> JOB ADDRESS 2-144-121 _q�atylT \� CITY/ZIP�y CQ ��1-ZO m <br /> CROSS STREETJ dr1 APN 001�- 40o-3-14 PARCEL SIZE��LAND USE AcPPLI�C(ATION# T A <br /> OWNER NAME ` oayQ�Beww-- PHONE J?y l--7/y y <br /> OWNER ADDRESS ? .6 1/' /� A2D CITY/STATE/ZIP 6 Ol L T" Ca !.6T-2— <br /> CONTRACTOR aS4_11is PHONE 552.2-1612-53 <br /> CONTRACTOR ADDRESS 9 A 1��� CITY/STATE/ZIP/►isJ-e—SY / CA, q535­1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C,IITTYY//SSTATTE/ZZIIP� ` <br /> LICENSE .i4 C-57 I I C-61 I I D-09 I Other NUMBER 462(=1,2JrL EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391)1 I Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural I I Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> i-I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well F1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> I i Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #of borings <br /> -I Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 1 New Pump I_I Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary 11 Air Rotary I I Auger F1 Cable Tool I I Push Point I I Other <br /> Proposed Well Depth . O ft Excavation in diameter 1 i Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 12– in Thickness/Gauge/ASTM Sched '1LY� I I Steel ><Plastic ❑ Stainless Steel 1_I Other <br /> Grout Seal DepthI h d ft I I Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> 'Bentonite(20%solids) I I Other <br /> Grout Placement Method Pumped -1 Free Fall Li Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 I DrillerPump Contractor I I Other <br /> 1 Concrete Pedestal IDi ensions:Width ft Length ft Thick in ❑ Christy Box I-1 Stove Pipe <br /> PUMP I SubmersiblerI 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 /> MIMIALIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209J) 953-76947 <br /> 6 <br /> SIGNED TITLE l�ht l�e� DATE -16-1/ <br /> JIJAY W, <br /> JUAC ulpf C <br /> LT EN A <br /> q7T <br /> —## <br /> EP/AR MENTI US O LY <br /> q <br /> Application Accepted By / Date C� I I 120( I Area Employee ID# u � <br /> Grout Inspection By' WI & Date 2 SPECIAL Well Permit <br /> Pump Inspection By Date I J WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ReceivedCh / Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash RemittedService Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />