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WELL/PUMP PERMIT { <br /> S`N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PE MIT CALL 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,( Q � <br /> JOB ADDRESS 0 C/QS k S -v CITY/ZIP' QC /S d/L 7�S .Z B� m <br /> �^ D <br /> CROSS STREET 4t Ve APN 136-1 V OO PARCEL SIZE ;.2.9J LAND USE APPLICATION# A <br /> �/ Q o b` m <br /> OWNER NAME (2I t 01 e ,,/1 7C�/L�► r( PHONE 1/'T-)-j 0 7 q1 / co <br /> OWNER ADDRESS Pfdbl.f- r br s /C/ liACOlA EC? CITY/STATE/ZIP /(7ab", co . t4 � e16 <br /> CONTRACTOR t :II"Ac d PHONE Zr.,ns—G cr 2r�p <br /> CONTRACTOR ADDRESS13CL-1S'. + d CITY/STATE/ZIP /fi aC/\LC/�. /✓VS'� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> qF <br /> LICENSE �7 ❑ C-61 [ID-09 ❑ Other NUMBER y3 / Z 20 EXPIRATION DATE %I 3� <br /> DOMESTIC WELL SAMPLING: ! General Mineral/Coliform Bacteria(4391) i 1 Dibromochloropropane(4392) i1 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private C+-Mgation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Rol eplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method -KTud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth A J�D ft Excavation f0 in diameter ❑ Open Bottom ravel Pack/Gravel Size 60 in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 1 x7 in Thickness/Gauge/ASTM Sched_ teel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth _O ft �at Cement(94 lb bag/5-10 gal water) &Sand Cement 10.3 :�:(� sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other s/K(Ry <br /> Grout Placement Method kKPumped ❑ Free Fall ❑ 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 /> CURRENTD ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS OMPENSATION LAWS. <br /> M IMUL111 24 HO A VANCE NOTICE REQUIRED FO%INSPECTIONlS S-Pj.EASE CALL (209) 953-7697 <br /> SIGNED TITLE G.���L f DATEIzq be <br /> D <br /> JO <br /> O O <br /> A <br /> DTRTMENT U •�E NLY / <br /> Application Accepted By Date '/� Area �I Employee ID#1�11z <br /> Grout Inspection By F\ ,_ `% --� Date --�->/�: � �i� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS egg i 3� <br /> PE Sc Received Che Amount Permit/ <br /> Codes Info B Cas mitted Date Service Request# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />