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WELL/PUMP PERMIT <br /> SAN JOAQUI!.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 /> /y � ItJ Cn <br /> / 4— <br /> JOB ADDRESS LCITYIZIP m <br /> PARCEL SIZE LAND USE APPLICATION# vCROSS STREET / APN <br /> M <br /> OWNER NAME � �/ �f�"� PHONES <br /> OWNER ADDRESS ' Lf CITY/STATE/ZIP <br /> CONTRACTOR - .`aS` �d C: r PHOONE !�6juA 7— 4ii`7 2-5 <br /> CONTRACTOR ADDRESSPrd CITY/STATE/ZIP �L✓��(�/L I �j <br /> SUBCONTRACTOR �� /- PI PHONE >�� 3 1 LY <br /> SUBCONTRACTOR ADDRESS \ CITY/STATE/ZIP I <br /> LICENSE <br /> C-57 Ll C-61 Ll D-09 ❑Other NUMBER ?._3O y EXPIRATIO DATA �— <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform acteria (4391)❑Dibromochloropropane (4392) r enic( 3 3) <br /> INTENDED USE ❑Dom esti c/PrivateA<lrrigation/Agricultural Industrial ❑Water Quality Monitoring ❑Soilp g/ terization <br /> ❑Public Water System <br /> If different from Owner Water y em arae uonlar m/77 <br /> 1e ne Number <br /> TYPE OF WORK flew Well ❑Replacement Well ❑Well Iteration/Modification ❑Other <br /> of borin e #of borings <br /> F-1 Monitoring Well(s) #of wells ❑Soil B ing(s) �' i Ge echnical <br /> []Out-Of-Service Well E]Out-Of- ervice Well Renew I ❑ r onn ion Repair <br /> .�lew Pum ❑Pum Replacement L]Pump Re air ❑ ise We .sin <br /> WELL CONSTRUCTION <br /> Drilling Method F]Mud Rotary ❑Air Rotary [-]Auger ❑Cable To ❑Push 4avel <br /> Proposed Well Depth ft Excavation _� in diam ter ❑OpPack/Gravel Size in diameter <br /> ❑Conductoor�Casing in diameter / Conductor C sing DepthftWell Casing Diameter� in Thickness/Gauge/ASTM Sched kl ❑StStainless Steel ❑Other <br /> Grout Seal Depth `;' ft ❑Neat Cement(94 lb bag/5-10 gal ater) anement 0 .-3 sack mix/7 gal water <br /> F-1 Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By rifler ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Le h ft Thick in [_]ChristyBox [-]StovePipe <br /> PUMP ubmersible❑Turbine ❑Other H 0 ump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICAT N AND THAT T WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUiN COUNTY ORDINANCES, STATE LAWS, AND RULE AND REGULATION I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRA ORS STATE LICENSE OARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIN M M 24 H UR ADVANCE NOTICE EQUIRED FOR INSPECT NS - PLEASE CALL (209) 953-7697' <br /> SIGNED i' TITLE 1.(J DATE /J �V <br /> 1000 00, <br /> 01 <br /> to <br /> A ''J <br /> ONM <br /> TFH H E A T <br /> DEPARTMENT USE ONLY <br /> Application Accepted By L' /ifL� Date 1 (✓ �,� Area I Employee ID# L�` <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump InsPection By _ Date _ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Construe Well Depth ft <br /> COMMENTS �' <br /> PE SC Received Affiount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> NY 0o3 �- . <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />