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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 �/ Q CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln <br /> 1)G(�Z© �Y ` Jl� CITY/ZIP oy►+�(�� 5 Z 2 b m <br /> JOB ADDRESS v-- r ! m <br /> CROSS STREET �P I2✓' APN i YO PARCEL SIZE �LAfID USE/APPLJ�ATION# <br /> (tdQSI JS�I�1�+ -7� m <br /> OWNER NAME Wl ice,l} (70.Z2. Q U PHONE <br /> OWNER ADDRESS 4/29 E ' �✓F§7,� C � j [ CITY/STATE/ZIP r <br /> CONTRACTOR `y_S_e'/ t � <br /> S ���GlLLLC1 PHONE2G— 7 <br /> i <br /> CONTRACTOR ADDRESS q 4 1164?y`_5­ CITY/STATE/ZIP m odes t—Lt ✓ u <br /> SUBCONTRACTOR PHONE 269 ( 2-2- <br /> SUBCONTRACTOR <br /> .ZSUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE2�2I <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE XDomestic/Private ❑ Irrigation/Agricultural ❑ 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 WORK6iTlew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> '❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method okMud Rotary,, ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth �2_8c ft Excavation -1,;7_ in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. in. Thickness/Gauge/ASTM Sched ❑ Steel APlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth Zoo ft D Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method gPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 6(Pump Contractor LiOther <br /> [iConcrete Pedestal ❑Dima sions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible[] 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE DATE <br /> fttz <br /> b <br /> a <br /> EP IRTMENT U E N L Y <br /> Application Accepted By Date f/ Area 4-/of07 Employee ID#111 � <br /> Grout Inspection By r:' ' r Date lG a ck ❑ 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 Check Amount Date Permit/ Invoice# Well ID# <br /> Co es Info B ash Remitted Service Request# <br /> 5 !1 Q <br /> D <br /> EHD 43-06 6/01116 WELL/PUMP PERMIT <br />