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WELL/PUMP PERMIT <br /> SAN JOAQUV,COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT f/J CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L 75 JS -2i /'��(C /t/ �� CITY/ZIP^ e m <br /> CROSS STREET {• ! APN I✓' ;�/ l 1 PARCEL SIZE�--r/ LAND USE APPLICATION# o <br /> OWNER NAMEi Ej � PHONE <br /> OWNER ADDRESS X, liol CITY/STATE/ZIP <br /> CONTRACTOR -�1 Z r PHONE y Z 7 2--5 <br /> CONTRACTOR ADDRESSPO 7 CITY/STATE/ZIP <br /> SUBCONTRACTOR C' PHONE ��r <br /> /ZJ� <br /> ✓'1 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE ?❑C-61 ❑D-09 ❑Other ` NUMBER ?�,26y ExPIRAMJO I AT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392) Are is(,3 3) <br /> INTENDED USE ❑Domestic/Private, Irrigation/Agricultural Industrial ❑Water Quality Monitoring ❑Soilp! g/ terization <br /> ❑Public Water System <br /> If different from Owner Water y em ame uontar N77 <br /> ne Number <br /> TYPE OF WORK flew Well ❑Replacement Well ❑Well Iteration/Modification ❑Other <br /> of borin #of borings <br /> El Monitoring Well(s) #of wells ❑Soil B ing(s) °' Ge echnical <br /> ❑Out-Of-Service Well ❑Out-Of- ervice Well Renew 1 ❑i r onn ion Repair <br /> �ew Pum ❑Pum Replacement ❑Pum Re air ❑Raise We asin <br /> WELL CONSTRUCTION <br /> Drilling Method [_]Mud Rotary E]Air Rotary ❑Auger ❑Cable To ❑Pushint/ ❑ ther <br /> Proposed Well Depth 611-L ft Excavation in diam ter ❑Open Bott ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conduct^Casing in diameter/r / Cor// Conductor C sing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched '�?l ❑Ste lastic E]Stainless Steel ❑Other <br /> Grout Seal Depth) ft ❑Neat Cement(94 Ib bag/5-10 gal ater) 5eand Cement / 0 ..-3 sack mix/7 gal water <br /> [:]Benton ite(20%solids) ❑Other <br /> Grout Placement Method� Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller ❑Pump Contractor ❑ Other <br /> [I Concrete Pedestal Lpimensions:Width ft Leoh ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑Turbine ❑Other H 1_j,_' ump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICAT NAND 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 IN/S.P,ECT NS - PLEASE CALL (209) 95s3-7697,E <br /> SIGNED i' TITLE W DATE <br /> _ 6 <br /> to <br /> A 6 110 016 <br /> i <br /> 10 <br /> PP <br /> ic <br /> T <br /> HEAAL H E A T <br /> v <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Lilk Lt tr),� Date t0io 0 IS Area � 1 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump InF;Pection By _ Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Construc Well Depth 4 ft <br /> COMMENTS C 1 <br /> VV <br /> PE SC Received Aftiounf Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />