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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 /> JOB ADDRESS 17 L <br /> ao S CITY/ZIP m <br /> �J D <br /> CROSS STREET APN® / PARCEL SIZE LAND USE APPLICATION# A <br /> OWNER NAME L 1 uc-c-At I PHONE y <br /> OWNER ADDRESS RX <br /> 7 CITY/STATE/ZIP <br /> CONTRACTOR AJA .'53n T111"41t /.PHONE <br /> � <br /> CONTRACTOR ADDRESS 1420 r'y c7PS CITY/STATE/ZIP <br /> SUBCONTRACTOR .�1�r7 CmsT 0— , PHONE �2_ 12.1 <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE J<C-57 ❑ C-61 ❑ D-09 f_l Other NUMBER 3 7 7 J 0-r EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial I 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 ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells [I Soil Boring(s) #of borings 11 Geotechnical— .- of bo �^ <br /> ❑ Out-Of-Service Well Li Out-Of-Service Well Renewal 11 Cross-Connection Repair -JUN o c � 49 <br /> joki1ew Pum 11 Pump 11Re Replacement Pum [IRe air Raise Well Casingv <br /> WELL CONSTRUCTIONH E/y�/RQU/NC <br /> Drilling Method�llud Rotary 11 Air Rotary L) Auger Cl Cable Tool F1 Push Point LlOP.-Other /y OTU <br /> Proposed Well Depths ft Excavation 1 _ in diameter LI Open Bottom 11 Gravel Pack/Gravel Size ,�TVc*"eter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 41, in Thickness/Gauge/ASTM Sched Z_,0 ❑ Steel J<Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) (,Sand Cement 10•-3 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method`441Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By Aller ❑ Pump Contractor ❑ Other <br /> ElConcrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> • PUMP ubmersible❑ 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 3A HO RA�DZANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697SIGNED �� TITLE a�L� DATE <br /> i V <br /> EP RTMENT US � QNLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By Date t 1 1 %9 ❑ SPECIAL Well Permit <br /> Pump Inspection By t fNncl9lG yl'in �1 Date�Za ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ln(L4� V W—tIL, 2!�?C&IA/5 JAI <br /> PE SC Received (10heclo Amount Date Permit/ Invoice# Well ID# <br /> Code1pfo Remitted Service Request# <br /> r� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />