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a <br /> WELL/PUMP PERMIT <br /> �'- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT C CALL /209 953-7697 FOR INSPECTIONS CEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 6 I l -L CITY/ZJP ✓5� `� I cry- rt� <br /> / D <br /> CROSS STREET fIl�jy i;,y APN b PARCEL SIZE LAND USE APPLICATION# �J S <br /> OWNER NAME / / ( PHONE2, <br /> OWNER ADDIm <br /> RESS r L v ��CITY/STATEILP �TLL� 7 -'f^ <br /> CONTRACTOR nn klz d14PHONE !�)�—� C <br /> CONTRACTOR ADDRESS 1:C. X Il iG CITY/STATE/ZIP M-Pel-ibh,� -��. �y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/7JP <br /> LICENSE )(C-57 :C-61 D-09 Other NUMBER 4 T 3 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i_:Dibromochloropropane(4392)i,Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial _Water Quality Monitoring i Soil Sampling/Characterization N �F <br /> Public Water System ^ _^7 <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AlterationlModfication ❑Other <br /> i Monitoring Well(s) #of wells SoilBodng(s) #ofbodrgs i!Geotechnical 0ofborings 0� <br /> ut-Of-Service Well Out-Of-Service Well Renewal �Cross-Connection Repair Sq 08 D �O� <br /> ew Pum Pum Replacement Pum Repair Il Raise Well Casing (! D <br /> WELL CONSTR C F pqQU� a <br /> Drilling Method Mud Ro Air Rotary Auger able Tool -!Push Point i_7 Other H / ON'q Co�N <br /> Proposed Well D th k Excev ion <br /> �,amet <br /> en Bottom Grav PacWG Size n diameter CEpq�I C uctor Casing in di ter / Conr Casi pthWell Casing Di ete in Thickness/Ga e/ TM Sched i Steel t I Plastic i I Stain eel rI Other <br /> Grout Seal pth ft i tCemen 94 Ib b0 gal water) :-i Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I Other <br /> Grout Placement Method 'i Pumped ❑Free Fall !i Other ri Retardant/Accelerator(name) <br /> PEDESTAL Installed By r:-Driller i:'�Pump Contractor $- Other G �h <br /> Concrete Pedestal❑Dimensions:Width_�k Length ft Thick n Christy Box Stove Pipe <br /> PUMP SubmerSibleI l Turbine i.'Other HP Pump Set k Standing Water Level <br /> 1,QQ�—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 A ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS O ATION LAWS. <br /> NIMU UR,,ADVAUGE NOTICE REQUIRED FIfNSSPf¢TION -PLEASE CALL(209 953 7697 <br /> SIGNED TITLE I DATE <br /> 44 to <br /> ART ENT U <br /> Application Accepted By e O Area Employee ID# <br /> Grout Inspection By Date =_ ECIAL ell Pemtit <br /> Pump Inspection 6 Data b,6 WAIVER Received <br /> Soil Boring Insppe(.3ion By Date Constructed Well Depth ft <br /> COMMENTS � �C 14e L l <br /> E' <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Info ash emitted Service Re est# <br /> 117 W <br /> EHD 4306 revised 4/14/18 WELL/PUMPPERMIT <br />