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WELLIPUMP PERMIT yruha� L(Cwn Lfilgn ffyo <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N <br /> JOB ADDRESS 61, t/-1 • GCITYIZIP ���' �� m <br /> D <br /> CROSS STREET bAk APN 2.043 076 105 PARCEL SIZE - LAND USE APPLICATION# P <br /> F.�'I-e Ir w+G �� +433 -900"1 m <br /> OWNER NAME Q !" 66fA V'<1 PHONE Z N <br /> OWNER ADDRESS ��/� 1(6q`D( W • G e-u".T L 1 r`6 1'—�1 CITYISTATEIZIP / ;-,I 114 c x1 q 5 I <br /> CONTRACTOR 1� dkSt_1 G]„ Y'1 l�ytf m �r. �/�PH,O/NE 5 ZZ- /OIILS <br /> CONTRACTOR ADDRESS 1101 &flZr5 V4 CITY/STATEIZIP j1Ajde % `0f - '7SSS-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSEC-57 EIC-61 El ❑Other NUMBER�f9�6 ,, EXPIRATION DATE 1-/-96'17 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial []Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: water systeM Name Uentact Name or Fhone Numuer <br /> TYPE OF WORK *&ew Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring #of borings s) ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal E]Gross-Connection Repair <br /> E]New Pump Ej Pump Replacement El Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION r <br /> Drilling Method .Mud Rotary El Air Rotary ❑Auger [-]CableTool ❑Push Point ❑ Other '1 <br /> Proposed Well Depth�� 2 ft Excavation 1in diameter ❑Open Bottom Gravel Pack/Gravel Sizein diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter& in Thickness/Gauge/ASTM Schad_295�> __. El Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /h a ft ❑Neat Cement(94 1b bag/5-f0 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall E]Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions: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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED <br /> SIGNED � —� TITLE OCH OIC DATE J? 17 <br /> E Vt RT Y � <br /> 01 <br /> EPARTMENT U E ONLY <br /> Application Accepted Date l Area*E] P Employee ID#� <br /> Grout Inspection By Date AL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring I spection By Date Constructed Well Depth ft <br /> COMMENTS <br /> "AAer cm Ir X <br /> PE SC Received Ch AmounttDate Permitl Invoice# We1110# <br /> Codes info as Re i edService Re uest# <br /> 520J-77 <br /> EHD43-06 6/01/16 WELL/PUMP PERMIT <br />