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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/PERMITp � CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 8lJ Jt.t-Vt - Iv m <br /> JOB ADDRESS CITY/ZIP ck m <br /> � <br /> n - D <br /> CROSS STREET j3eec'4� (?j APN Ida-00- 170 PARCELSIZE 1()'C) LAND USE APpPL`ICATI�ON#oar <br /> OWNER NAME �CLIJI�✓' �u � ��~ �PHONE 9Ot7"'VTIad N <br /> OWNER ADDRESS - CITY/STATE/ZIP <br /> CONTRACTOR `�� 5�S r� Lam/ PHONE <br /> CONTRACTOR ADDRESS /�/ L�L' CITY/STATE/ZIP ,/ld.,46, o <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE_2©�2l <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial b 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 9 New Well ❑ Replacement 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 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth J_'NO ft Excavation -5 in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter.L1 in Thickness/Gauge/ASTM Sched 0— ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Grout Seal Depth .Y0 <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor 0 Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 0 Submersible❑ Turbine 0 Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76977 <br /> SIGNED 11.Ci �'��nallleC�►.y TITLEDATE <br /> ry <br /> TA <br /> e <br /> N F Q <br /> N O <br /> D P MENT USE ONLY <br /> T ,y <br /> FST <br /> Application Accepted By ZffiDate all Area Employee ID#knh* <br /> Grout Inspection ByDate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ✓ O ft <br /> COMMENTS <br /> PE SC Received ec / Amount Permit/ <br /> Co es Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />