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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 /> of <br /> JOB ADDRESS 1,.44/ M KIM� ✓ 7—L CITY/ZIP �!�/�G/V 9 m <br /> �,/� i ! D <br /> CROSS STREET IVC y��y //��"�Zf APN ©��I 1 3"/hC) 11 PARCEL SIZE 7 7LAND USE APPLICATION# <br /> �fT /7Z/I/��1� /L�� PHONE/'4n9) &f- <br /> OWNER <br /> -.�p33 <br /> U) <br /> OWNER NAME <br /> OWNER ADDRESS CITY/STATE/ZIP n <br /> CONTRACTOR _/,//`!/(/IS� L�l ��f"`�/G� PHONE�'71�J/� � <br /> CONTRACTOR ADDRESS f— D V(/1 - �Y� /�£ CITY/STATE/ZIPS <br /> SUBCONTRACTOR ��L ,��LI~ Lf,/L1�r PHONE <br /> 0 <br /> SUBCONTRACTOR ADDRESS CITY/STATE//ZIP / ? <br /> LICENSE C-57 61 LI D-09 U Other NUMBER 0EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USEomestic/Private U Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring Ll Soil Sampling/Characterp�igs�► <br /> ❑ Public Water System ••99��```y <br /> If different from Owner: Water System Name Contact Name or Phone Number AfA 11 <br /> TYPE OF WORK ❑ New Well '*eplacement Well ❑ Well Alteration/Modification ❑ Other _ 7 <br /> #of borings -A7 J®, ori <br /> ngs TzqVIlff <br /> Ll Monitoring Well(s) #of wells U Soil Boring(s) 11 Geotechnical ",/0Ylj/� <br /> Ll 11Out-Of-Service Well <br /> Out-Of-Service Well Renewal ion Repair H � co"",N <br /> ew PumPum Replacement 11 PumRepair ❑ Rase Well Casing <br /> WELL CONSTRL46TION r <br /> Drilling Method VAud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 3, 70 ft Excavation � in diameter I I Open Bottom �Wavel Pack/Gravel Size in diameter <br /> ❑ Conductor asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_� in Thickness/Gauge/ASTM Sched Z-4 AV - M ❑ <br /> 1 Steel astic Stainless Steel to Other <br /> Grout Seal Depth /del' — -ft ❑ Neat Cement(94 Ib bag/5-10 gal water) / ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped U Free Fall f I Other I1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By CI Driller1-pump Contractor ❑ Other <br /> Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine 11 Other HP11 <br /> Pump Set 21V ft Standing Water Level s <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 /> MINI 4 OUANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)953-7 7 <br /> SIGNED TITLE DATE <br /> I <br /> Ar <br /> I <br /> I <br /> -r - 7 <br /> I <br /> Vi <br /> PO <br /> DEPARTMENT J S E NII Y I <br /> DEPARTMENT US��Ej00NLY n <br /> Application Accepted By S� Date_�t�," Area "l Employee ID# <br /> Grout Inspection By I.. Date 3 l3 Zy ❑ SPECIAL Well Permit y <br /> Pump Inspection By j-Irt"M 4, ti'o (g dt�L, tkot` Date ��`�(largo 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth I ft <br /> COMMENTS r' UrM#L.— in 4 <br /> J <br /> ,cf7�w x,Y W A O i7 3 f <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br /> WELL/PUMP PERMIT <br /> EHD 43-06 8101/16 <br />