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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 /> 1 ,L` -, ­7 cn <br /> JOB ADDRESS 1 / it_r/ CITY/ZIP 7t a L m <br /> D <br /> CROSS STREETC7/� T APN A PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME / PHONE s' <br /> i <br /> OWNER ADDRESS lJ G CITY/STATE/ZIP <br /> CONTRACTOR /<1I PH ONE����/J,/j�C�//�j7L/7 ///���� <br /> CONTRACTOR ADDRESS ` L 1 _ CITY/STATE/ZIP <br /> SUBCONTRACTOR /`- C��7"/1 l`/h-�'-qu PHONE 27 j <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 11 C-61 !I D-09 ❑ Other NUMBER 3 / / ✓V EXPIRATION DATE• — <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural I I Industrial I I Water Quality Monitoring f Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Jew Well LI Replacement Well I Well Alteration/Modification I Other <br /> L Monitoring Well(s) #of wells I Soil Boring(s) #of borings i 11 Geotechnical #of borings <br /> ❑ Out-Of-Service Well 1 Out-Of-Service Well Renewal ICross-Connection Repair <br /> ew Pump I I Pump Replacement Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _�llud Rotary i! Air Rotary Auger Cable Tool G Push Point Other <br /> Proposed Well Depth,- CI ft Excavation in diameter I I Open Bottom jCGravel Pack/Gravel Size in diameter <br /> I! Conducto asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steellastic Stainless�SteeL Other <br /> Grout Seal Depth r ft I i Neat Cement(94 lb bag/5-10 gal water) ' and Cement sack mix/7 gal water <br /> I Be tonite� (20%solids) Other <br /> Grout Placement Method ' Pumped " Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i i Driller i Pump Contract 7. Other <br /> Concrete Pedestal I(Dimensions:Width ft Length ft Thick in I I Christy Box L Stove Pipe <br /> PUMP ";Submersible: Turbine 'I Other HP _ Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICAT!ON AND THAT THE WORK VYILL 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 4 HOU_. ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLEIf i <br /> DATE <br /> I Alli, <br /> 14 U <br /> n 4n <br /> L Hi <br /> - , <br /> l <br /> <_ <br /> Q IN C UN <br /> Jill E A R T M E N T U E ONLY ENVIRONMENTAL <br /> HEALTH DEPR <br /> Application Accepted By Dale Area Employee ID# <br /> Grout Inspection Byru�Urlnl_ in���(I�C�A1�l��M Date 1k.( ❑ SPECIAL Well Permit <br /> Pump Inspection By +w�(.S[ Far ��� "i. Date �3/�1 Zti' ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS F G <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Co es lato By Cash Remitted Service Request# <br /> L �. <br /> INI <br /> Z <br /> END 43-06 801/16 WELL/PUMP PERMIT <br />