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At 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 -70 LZ14c) � CITY/ZIP O ti m <br /> D <br /> r APNPARCEL �LAND E APPLICATION#CROSS STREET E <br /> OWNER NAME RPHONE — I <br /> OWNER ADDRESS S O �� e ' 1 CITY/STATE/ZIP <br /> CONTRACTOR PHONE 8 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP rY�o�S-��, ck �t� 7vf0 <br /> SUBCONTRACTOR PC PHONE <br /> SUBCONTRACTOR ADDRESS N I P, CITY/STATE/ZIP <br /> LICENSE 57 I 1 C-61 D-09 Other NUMBER2_W8 I EXPIRATION DATE I , <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> I I Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well (I Replacement Well ❑ Well Alteration/Modification 1.1 Other <br /> Monitoring Well(s) #of wells [ISoil Boring(s) #of borings Geotechnical #of borings <br /> I i Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Repair <br /> r I New Pum C Pump Replacement ❑ Pump Repair ^ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method .Mud Rotary Air Rotary Auger I Cable Tool ❑ Push Point I I Other <br /> Proposed Well Depth,LASD__ft Excavation 1� in diameter rI Open Bottom XGravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_& in Thickness/Gauge/ASTM Sched _6D&24 f1 Steel XPlastic ! Stainless Steel Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal wate/) !I Sand Cement sack mix/7 gal water <br /> �enton4umped <br /> 0%solids) L1 Other <br /> Grout Placement Method 1 Free Fall I Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1 Pump Contractor [I Other <br /> I 1 Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in f i Christy Box I I Stove Pipe <br /> ] <br /> PUMP 1 Submersible❑ Turbine I Other HP Pump Set ft Standing Water Level ft <br /> 1 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 48 HOUR ADVANCE NOTICE SREQU15A FO <br /> , INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> TIT —19 <br /> SIGNED LE DATEzQL <br /> AN <br /> s <br /> H N <br /> T <br /> T M E N T U S E O N L Y <br /> Application Accepted By Date A Area Employee ID#/%OW <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount pate, Permit/ Invoice# Well ID# <br /> Codes nfo B � ash RemittedService Request# <br /> Z / G <br /> EHD 43-06 8/01/16 ♦ WELL/PUMP PERMIT <br />