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I ` WELL/PUMP PERMIT <br /> SAN JOf OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON#V%W TOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONSEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Lo^e <br /> / T CITY/ZIP f 4 la2la `� 9 S 3 to N <br /> O �Q� /•C{ IL //�� M <br /> M <br /> G' D <br /> CROSS STREET }{� � <br /> ' Q <br /> I � „Q__r1 I APN '1>DC7• PARCEL SIZE LAND USE <br /> /APPLICATION <br /> �y�# A <br /> OWNER NAME �p) r�Y�{ y PHONE t0 <br /> 0q- ~ � r�/� <br /> OWNER ADDRESS 09 ( Lr(/l�-L1��\C t CITYISTATE/ZIP 64L"a le— j r4 p9 S?6 1 <br /> CONTRACTOR `a=L �� �1`7%A j _��f y��PHONE 1��•/f� iQJ�� <br /> CONTRACTOR ADDRESS 1 -` 1���1A CITY/STATE/ZIP /rIQQ e_STD CA �S3 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIT <br /> Y/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 I1 Other NUMBER IOfO&2Z EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring I I Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew Well eplacement Well ❑ Well Alteration/Modification Other <br /> 1-1 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 /> 11 New Pump Pump Replacement ❑ Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary Air Rotary Auger i Cable Tool i Push Point I Other <br /> Proposed Well Depth #I-C-40 ft Excavation I 11 in diameter Open Bottom )(Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter a2 in Thickness/Gauge/ASTM Sched�� i Steel lastic Stainless Steel Other <br /> Grout Seal Depth /00 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> bentonite(20%solids) Il Other <br /> Grout Placement Mgthod I Xurnped I I Free Fall i Other i i Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1 ump Contractor ❑ Other <br /> ❑ Concrete Pedestal I JD!nliesions:Width ft Length ft Thick in i Christy Box i I Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine L 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 /> MI IMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED V ' TITLE Viy+N.!e DATE <br /> A. <br /> P1 <br /> A <br /> EV <br /> TY <br /> FjkLTH E EP R M NT <br /> D PA T M E N T U Eh NL� �' <br /> Application Accepted By Date Area Employee ID#I'/,;t %1 v1r1//7 <br /> Grout Inspection By e �L Date I I 'SPECIAL Well Permit r <br /> Pump Inspection By Date I 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 /> Codes fo B Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />