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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 [, LL(209)A53-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED LA <br /> JOB ADDRESS / G ��l CITYIZIP ///� •Cf / 5V 7 m <br /> m <br /> D <br /> CROSS STREET 4-'104 APN22 ep -I60 -Z,q 'ARCEL SIZE2 7— LAND USE APPLICATION# A <br /> �t //�� Q M <br /> OWNER NAME /• W A P PHON / <br /> �L '/� IC 9 <br /> OWNER ADDRESS/ W� e CITY/STATE/ZIPS d/� <br /> CONTRACTOR �YI`R 1Ifla <br /> PHHO/ry/�_p24. 42 6 <br /> CONTRACTOR ADDRESSO-OO � . j'7 y CITYISTATE/ZIP�/�/O('/l C.4- 9.T3GV6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C11`/57 I C-61 D-09 I Other NUMBER 7 L EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(439 1) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 4"yr"gation/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 (ilQew Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) If 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 (/M/ <br /> ud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth_a.�ft Excavation­2__Q�_in diameter Open Bottom Gravel Pack/Gravel Size 6)(/2 in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter LZ in ThicknA s/Gauge/ASTM Schad SJOR 2( Steel GPPtastic Stainless Steel Other <br /> Grout Seal DepthS�ft -Keat Cement(94 lb bag/5-10 gal water) 0Sand Cement ZC sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ✓Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor they <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 /> CURRENT AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C PENSATION LAWS. <br /> MI MU R ADVANCE NOTICE REQUIRED FOR INSPECTIO1I-PfASE CALL(209953-7697 <br /> m <br /> SIGNED TITLEa�JA^e ff� DATE< <br /> OF <br /> EIEN7" <br /> VED <br /> 5 Z010 <br /> IN COUNTY <br /> D P R T M E N T S E -7N�L Y H D MSN-rAL <br /> Application Accepted By � at� ZO Area n cEmployee ID# /� MENT <br /> Grout Inspection By Date f 2 SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS BL ((JFLLU .9A n1nom Eqd <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B slitRemittedService Request# <br /> 3 I -Lt; <br /> EHD 4306 revised 4/14/18 WELL/PUMP PERMIT <br />