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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 c �CALL t209 953-7697 FOR INSPECTIONS EXPIRES 1YEAR FRO�-M/ DATE ISSUED <br /> JOB ADDRESS 1�^L <br /> ' Z 10 J• �-tJ M r 5 CITY/ZIP,1}. (� <br /> r-acy -1 S3 7 / m <br /> D <br /> ` f u PARCEL SIZE LAND USE APPLICATION# <br /> CROSS STREET J• �(a�fit CO . APN 2-10 -I'tO- I� �,� O <br /> OWNER NAME V USO PHONE L To ` En <br /> OWNER ADDRESS ?1 5- Lar"yyNCr5 CITY/STATE/ZIP"-I—CtQ , 0`4 152577 <br /> CONTRACTOR qt O�I T1� \ Ca..-LnC - PHONE ��y�'11 \15` — <br /> 1 1 1 <br /> CONTRACTOR ADDRESS I 1 U CITY/STATE/ZIP od,p W5r-O' P 9 53� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP c <br /> LICENSE -57 ; C-61 C! D-09 I I Other NUMBER 2-`05 13 EXPIRATION DATE J `��7 <br /> o <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE omestic/Private Irrigation/Agricultural 11 Industrial Water Quality Monitoring 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 ❑ Replacement Well I I Well Alteration/Modification I I Other <br /> I I Monitoring Well(s) #of wells LI Soil Boring(s) #of borings I I Geotechnical #of borings <br /> ❑ Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum I- Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary - Air Rotary 1 I Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depthrft Excavation I_ in diameter ❑ Open Bottom *ravel Pack/Gravel Size in diameter <br /> !_I Conductor Casing H�0. in diameter / Conductor Casing Depth KJ ct ft <br /> Well Casing Diameter-15- in Thickness/Gauge/ASTM Sched �Slpf—?L I 1 Steel Plastic i I Stainless Steel I I Other <br /> Grout Seal Depth k0 0 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> 'X' pentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall Other I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor I I Other <br /> i Concrete Pedestal I IDi ensions:Width ft Length ft Thick in Christy Box i' Stove Pipe <br /> PUMP ! Submersible❑ Turbine i 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 /> MINIMUM 48 HOUR ADVANCE NQTICE RE C D R INSPECTIONS - PLEASE CALL (209) 953-76697 n <br /> SIGNED J Jr1p TITLE �� DATE <br /> Pm <br /> i y <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout InspectionBy Date 6A120M ❑ 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 Permit/ <br /> Codes Info B s Remitted Date Service Re uest# Invoice# Well ID# <br /> O f <br /> EHD 43-06 3/01/16 WELL/PUMP PERMIT <br />