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111. 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 �y EXPIRES 1 YEAR FROM DZ <br /> ATTE ISSUED <br /> JOB ADDRESS Iti i� �/4 �i CITY/ZIP /�(��� q5� / ( m <br /> D <br /> CROSS STREET S l��C WP! /-It-)f APN/ (J r Lebl PARCEL SIZE AND USE APPLICATION# 0 <br /> OWNER NAME M L Fc:`xt S(% ` /'�S��/�t'S, PHONE 7•�J -JC� I �'-7g� M <br /> OWNER ADDRESS S /�,`�/tIL�I L T CITY/STATE/ZIP 77\)G tG i c.lJ <br /> CONTRACTOR J_ e, / o: f(l/J�I� j" C �/L >✓ PHONE,)(." <br /> CONTRACTOR ADDRESS ' I / ]I' �[ /�IfYI��r L/i' CITY/STATE/ZIP / y?"'j C V, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS (CITY/STA/TE/ZIP J <br /> LICENSE 'AC-57 C-61 I I D-09 I Other NUMBER qS S EXPIRATION DATE �, 9 <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ?L'Domestic/Private i Irrigation/Agricultural I Industrial i I Water Quality Monitoring 1' Soil Sampling/Characterization <br /> 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 I Well Alteration/Modification I i Other <br /> ❑ Monitoring Well(s) #of wells i I Soil Boring(s) #of borings i 1 Geotechnical #of borings <br /> ❑ Out-Of-Service Well LI Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> New Pump I Pum Re lacement f I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary I Auger Cable Tool ❑ Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Cl Open Bottom Gravel Pack/Gravel Size in diameter <br /> CI Conductor Casing in diameter / Conductor Casing Depth ft <br /> .Nell Casing Diameter in Thickness/Gauge/ASTM Sched !I Steel 11 Plastic I I Stainless Steel 1 1 Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped I I Free Fall Other i 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller u Pump Contractor Other <br /> Ll Concrete Pedestal f7Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP XSubmersible I Turbine 11 Other HPif- Pump Set U ft Standing Water Level r 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 /> ,MN 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED / TITLE DATE 62 J� _ 1 <br /> U� <br /> O <br /> T <br /> P T M E N T US E N L Y <br /> Application Accepted By Date V Z� C Area. <br /> Employee ID <br /> Grout Inspection By Date 1 SP4wov <br /> ECIAL Well Permit <br /> Pump Inspection By �I , � lOsl,t �,a Date 1 l..f 20.1,a WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Cods Info B emitted Date Service Request#jo� Invoice# Well ID# <br /> YOGI­77— <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />