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� r ! <br /> WELL/PUMP PERMIT <br /> SAC UIN I H PARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> f A °gip 222 CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> J J� y <br /> JOB ADDRESS ��'.� CITY/ZIP /� / m <br /> ��1 D <br /> CROSS STREET (p/ �. G�� API V PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME1 J PHONE — `�! U) <br /> its <br /> OWNER ADDRESS :2"d4- CITY/STATE/ZIP I <br /> CONTRACTORF���-JLJ« PHONE <br /> CONTRACTOR ADDRESS-A z;- z p CITY/STATE/ZIP L����/✓/`-1 �� <br /> SUBCONTRACTOR Gil���§ � PHONE 32_ - .3 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 6-24/ <br /> LICENSE .3.<C-57C-57 11C-61 11D-09 CI Other NUM13ER��';7736S _2l EXPIRATION DATE l� <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE .Q::Oomestic/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 WORK ❑ New 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 /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method+--Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3 LC) ft Excavation -1 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched '7_0 ❑ Steel js�Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ZJD ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement l(7, sack mix/7 gal water <br /> ❑ Bentonite(20%solids) Ll Other <br /> Grout Placement Methods Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Xbrilier ❑ Pump Contractor ❑ Other <br /> ElConcrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP +Submersible❑ Turbine 17 Other HP -2— 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 /> MINIM U ,48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTION/S - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLEL`' ?�J �6 LJ�G" DATE <br /> A A K9° <br /> e 1 <br /> N uff p <br /> I O M <br /> A T <br /> PARTMENT U E ONLY e, <br /> I �! <br /> Application Accepted By q/ n Date V Area Employee ID# <br /> Grout Inspection By (I/ ORA / Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspe ion By Date Cons rutted Well Depth ft <br /> COMMENTS <br /> I <br /> PE SC Received Check#/ IjAnnount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> l w! Z gly ZZ1 01 <br /> +✓ L i0 r <br /> � � Z -� loLiq w 3 <br /> fin a.92. <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />