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WELL/PUMP PERMIT <br /> S/�: 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 1QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> NC.`.'q-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> 1 YEAR FROM DATE ISSUED Ln <br /> �/ /73 I� ,o � / CITY/ZIP �rl7 / _ m <br /> JOB ADDRESS y <br /> 0 <br /> CROSS STREET I�VV,-t� APN PARCEL SIZ LAND USE APPLICATION# X <br /> �s m <br /> OWNER NAME .S. t C a �PH'ONE�2e/ �Celef1 <br /> OWNER ADDRESS ell CITY/STATE/ZIP :57e IBN <br /> CONTRACTOR L PHONE ;? <br /> CONTRACTOR ADDRESS � _ � �{ CITY/STATE/ZIP �1��t7 /.�/�/7/7.5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE � C-57 ❑ C-61 ❑ D-09 Other NUMBER�7�1� EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ADomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring l7 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK /'New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> 11Monitoring Well(s) #of wells L1Soil Boring(s) #or borings F Geotechnical #of borings <br /> r <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 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool I I Push Point ❑ Other <br /> Proposed Well Depth305 ft Excavation, /y in diameter ❑ Open Bottom A Gravel Pack/Gravel Size Ue, in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter f�Z in Thickness/Gauge/ASTM Sched Z/ ❑ Steel A'Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth /y_ft ❑ 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 Limped [) Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,Driller ❑ Pump Contractor ❑ Other <br /> Concrete Pedestal [_]Dimensions:Width -.r ft Lengthft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP XSubmersible❑ 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 /> MI:=DVAW,MTICE REQUIRED FO�Rr INSPECTIONS'- PLEASE CALL (209) 953-7697 q <br /> SIGNED TITLE GG5f/I�f1 DATE <br /> T77 <br /> � Ur <br /> AN JO Q INC U <br /> h EV TIT-1 <br /> EP RTME14T U E ONL <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By c Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Pxh;ijjy,t G [1 WAIVER Rece7c, <br /> y'� <br /> Soil Boring Inspection By Date Constructed Well Depth v ft <br /> COMMENTS ' <br /> PE SC Received Ch ck#/ Amount Date Permit/ Invoice# Well ID# <br /> jZodep Info Ely A V sh Reitted. Service Request# <br /> 13 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />