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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 1 ��AA I• -CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 91k ` J"l�(y�(J l, RA CITY/ZIPfCQ�(/�1 Cq n%�! m <br /> n p /� D <br /> CROSS STREET l QYy��JL t i APN PARCEL SIZE /,��y LAND USE APPLICATION# A <br /> OWNER NAME &e6(Ar^ CareQ l tie roA PHONE ��r /f •y( <br /> OWNER ADDRESS 1��G bx a3 CITY/STATE/ZIP S`e, ` E q 53L <br /> CONTRACTOR o -tkl PHONE l�2A_jJ? <br /> CONTRACTOR ADDRESS tL9 rS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/SST�T��A''T'EIZIP <br /> LICENSE -57 ii C-61 I I D-09 I I Other NUMBER (06e L Z EXPIRATION DATE G"� <br /> DOMESTIC WELSAMPLING: 11General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane (4392)[1Arsenic(4393) <br /> INTENDED USE f omestic/Private LI Irrigation/Agricultural Industrial ❑ Water Quality Monitoring I i Soil Sampling/Character <br /> Public Water System � ���` <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well eplacement Well ❑ Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical 2019 <br /> ❑ New Out-Of-Service WPll 0 um Replacement ❑ Pump RepaireOut-Of-Service Well Renewal Cross-ConnectRaise Well Casing Repair J ENVIAQUIN COON <br /> WELL CONSTRUCTION LTH DEpAcry L <br /> RTMENT <br /> Drilling Method Mud Rotary Air Rotary I Auger I Cable Tool 1 Push Point I I Other <br /> Proposed Well Depth ♦�00 ft Excavation 12_ in diameter ❑ Open Bottom X✓Gravel Pack/Gravel Size in diameter <br /> 11Conducto Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 0) CX02 n Steel Plastic Stainless Steel i Other <br /> Grout Seal Depth 2-00 ft I Neat Cement(94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> y1(Benton e(20%solids) I Other <br /> Grout Placement Method mped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller ump Contractor I i Other <br /> I Concrete Pedestal I IDimensions:Width ft Length ft Thick in I Christy Box I I Stove Pipe <br /> PUMP I I 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 /> MINIMU 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9953-769 9 <br /> SIGNED r TITLE dGJ�b DATE / <br /> u <br /> 7 <br /> i t I I 1 1. 11 1 1 1 1 1_1 <br /> 1 <br /> EP AKRTMENT U 5 A <br /> 1% <br /> Application Accepted By Date Area /4 '7 Employee ID#f14fQ _�N7 <br /> Grout Inspection By '. �%I /111 Date �l f 1 1 SPECIAL 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 e Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> Ilf- <br /> 8:P z/,& z (A XMM77 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />