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r WELL/PUMP PERMIT <br /> SAN JOAOUIN 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 <br /> Il838 —So-" �1 CITY/ZIP rn <br /> � � m <br /> � /ren <br /> D <br /> CROSS STREET tt✓G'neclw,- APN 16,14"70- 170 PARCEL SIZE /G*C) LAND USE A?,?,6PLICATION#o A <br /> OWNER NAME �V� CTu �P/HONE ?O <br /> OWNER ADDRESS ' CITY/STATE/ZIP 7f-C9G� � <br /> CONTRACTOR "�+l `yJ�S�n �� �/ y��PHONE <br /> CONTRACTOR ADDRESS / ( fj1'��J + CITY/STATE/ZIP rno es-,6 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE .20�21 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 1.1 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 /> LI Monitoring Well(s) #of wells D 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 XMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter a in Thickness/Gauge/ASTM Sched 4ao _ ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth It ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement 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 ❑ Other <br /> Li 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MIpN//IMUM/48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209))) 953-769(7 <br /> SIGNED l/ L-e �6alle ! TITLE D,, JII�e, DATE <br /> i <br /> ti o <br /> ti o <br /> _qyE P TMENT USE ONLY �TiLjF <br /> MT Application Accepted By Date Area Employee ID#kn4�*� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received y <br /> Soil Boring Inspection By Date Constructed Well Depth ` 0 ft <br /> COMMENTS <br /> PE SC Received ec / Amount Date Permit/ Invoice# Well ID# <br /> codes Info —By as Remitted Service Re uest# <br /> LP2 <br /> WELL/PUMP PERMIT <br /> EHD 43-06 8101/16 <br />