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WELL/PUMP,:PERMIT <br /> SAN JOAdCfIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)466-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED <br /> 1y1, to <br /> JOB ADDRESS U 64,9 %1 A V\ G CITY/ZIP !e f �%� m <br /> D <br /> CROSS STREET APN 20.0 "0I7 G G PARCEL SIZE A. AND USE APPLICATION# z <br /> y <br /> OWNER NAME 0,V\ �[Y`I n�` �I��'� GIY)-P - / PHONE �-``_ y! <br /> OWNER ADDRESS �'o' 3o X L Q `O J CITYISTATE/ZIP ` t� I�Q�T I' J- <br /> CONTRACTOR CA l t I' I^ f�� i,�' V\C �/PHO/'NE 52L— 1 q 2- cl- <br /> CONTRACTOR ADDRESS i 1 V P{�J CITYISTATE/ZIP !Y r"d, G "^+✓ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR' A <br /> DDRESS CITY/STATE/ZIP j <br /> LICENSE -, C-57 11C-61 ❑ D-09 [iOther. NUMBER. EXPIRATION DATE `9}1 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE XDomestic/Pfivate ❑ Irrigation/Agricultural ❑ Industrial ❑Water Quality Monitoring ❑Soil Sampling/Character' M <br /> ❑Public Water System 4zr <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF:WORK ❑New Well - Replacement Well U Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑SoilBoring(s) pofbodngs ❑Geotechnical%./nofborm 19 <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair /y W RAN/NCOUN <br /> ❑New Pum ❑Pum Replacement ❑ Pum Repair ❑Raise Well Casing TfI NFN <br /> WELL CONSTRUCTION MFNT <br /> Drilling Method Xvlud Rotary ❑Air Rotary ❑Auger ❑�pble Tool ❑Push Point" 0 Other <br /> Proposed Well Depth2'� _ft Excavation /Z in diameter ❑Open Bottom XGravel Pack/Gravel Size n diameter <br /> ❑Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. in„Thickness/Gauge/ASTM Sched_�j L ❑Steel lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth Imo+ ft ❑Neat Cement(94/b bag/5-10 gal water)_ ElSand Cement sack mix/7 gal water <br /> 1 <br /> Oeht0 it (209% solids) ❑Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller KPump Contractor ❑ Other <br /> D Concrete Pedestal 0Dimensions:Width ft Length - ft Thick in ❑Christy Box ❑Stove P7-n--- <br /> au MP <br /> ipePUMP ❑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 /> MINJMljA48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> C,c.�N, r <br /> SIGNED --' .L.In 1 �TITLEDATE <br /> � lPl <br /> ego <br /> Y11 (4 <br /> YI L4 <br /> I I <br /> ll <br /> f <br /> L I <br /> { <br /> f <br /> PA TMENT USE NLY ,` ) <br /> Application Accepted B r Date` Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Iryspection By Date —t Constructed Well Depth ft <br /> COMMENTS C/EALi ~i ii `�l1` q%/(iI/ LAI <br /> PE SC CRecelvedChec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Re Itted Service Re uest# <br /> �/� G�.)C 0 W1D55 <br /> 1rJ 0 q <br /> 2 - .Io 0 0 <br /> ,4 <br /> EHb 43-06' 8/01/16 - WELL/PUMP PERMIT <br />