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WELL/PUMP PERMIT <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 /> y rSea/.+� Ca 9.f 32,6 <br /> JOB ADDRESS lJ 2 La w r�n e 2 CITY/ZIP im <br /> 4 D <br /> CROSS STREET 4L&t' �� APN 2 1`0?d _� PARCEL SIZE l•7OLAND USE APPLICATION# 0 <br /> OWNER NAME P-X - aid V<J 1VIC'� 1—:5-e PHONE OL�$— 3$23 <br /> OWNER ADDRESS 1-1607- /h G`G CITY/STATE/ZIP {_5-eQ/•,h ICg q S3Z� <br /> CONTRACTOR Ma`sc�lylif/^► 1 �L�,J ` APHONNE 572--1 !2j?" 2 ^/ <br /> CONTRACTOR ADDRESS I —` • r � r� `tel CITY/STATE/ZIP/V l[X�1{S,10/ CAQ gy?5 J <br /> SUBCONTRACTOR PHONE `Z0 <br /> SUBCONTRACTOR ADDRESS // 69& <br /> C��ITT�Y//S�ST��A��TE/ZIP <br /> [ILICENSE XC-57 [j C-61 D-09 ' 10 <br /> Other NUMBER Z21 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: r1 General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Cl Irrigation/Agricultural !_' Industrial Water Quality Monitoring 11 Soil Sampling/Characterization <br /> 1_I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well I I Replacement Well ❑ Well Alteration/Modification LI Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings iJ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> ❑ New Pum (I Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary i I Air Rotary E Auger ❑ Cable Tool ❑ Push Point Other <br /> Proposed Well Depth 0 ft Excavation { 2— in diameter LI Open Bottom )Gravel Pack/Gravel Size in diameter <br /> i ConductCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 9 in Thickness/Gauge/ASTM Sched 2-JCXd ❑ Steel Xlastic n Stainless Steel I I Other <br /> Grout Seal Depth �4V0 ft 1_I Neat Cement(94 Ib bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> Depth_ <br /> (20%solids) [I Other <br /> Grout Placement Method _ umped ❑ Free Fall ❑ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Xump Contractor I; Other <br /> Concrete Pedestal []Dimensions.Width ft Length ft Thick in i i Christy Box Stove Pipe <br /> PUMP ❑ Submersible F] Turbine II 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 Q <br /> SIGNED TITLE AD P 44/`r e DATE <br /> All <br /> � r <br /> Owl <br /> X <br /> c� <br /> t iR <br /> O <br /> P A T M E N T U S)E 9 N L Y <br /> Application Accepted By - ate Area Employee ID#hibm <br /> Grout Inspection By / Date I PECIAL Well Permit <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 I fo Cash Remitted Service Request# <br /> � 370 •�-� Gid <br /> 3�Ofo h <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />