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t `t <br /> 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 LNSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 4— , CITY/ZIP , m <br /> lJ / r D <br /> CROSS STREET /nt_� �i()/A APfN�J7!l I o 6�y PARCEL SIZE G SUS LAND USE APPLICATION# !1 0 <br /> co <br /> OWNER NAME ( Z.d 67 r�J err G�l� fL/ f PHONE ✓ J J / <br /> OWNER ADDRESS �R�h f✓ CITY/STATE/ZIP ry (y <br /> CONTRACTOR ` j J�A��S h ! �'U �1 'PH/ONES j3 3 yy- <br /> 7 CITY/STATE/ZIP �/� �`V/ S <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR / ( V* PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 ❑ C-61 ❑ D-09 CI Other NUMBER EXPIRATION DATE C) <br /> DOMESTIC WELL SAMPLING: eneral Mineral/Coliform Bacteria (4391) Ibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE ><Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK /K-New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> F1 Monitoring Well(s) #of wells 11 Soil Boring #of borings s) ❑ Geotechnical f <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair EVQVED <br /> ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION p 2019 <br /> Drilling Method,,WNud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SAN_r,,._ <br /> Proposed Well Depth_) Lo ft Excavation in diameter 1 I Open Bottom ° <Gravel Pack/Gra !RiWU/N��CO( meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft �H DEM ME <br /> Well Casing Diameter K_ in Thickness/Gauge/ASTM Sched I Steel Mastic LlStainless Steel ❑ Other NT <br /> Grout Seal Depth %) Q ft ❑ Neat Cement(94 lb bag/5-10 gal water) ',;�`Sand Cement A)1 sack mix/7 gal water <br /> U Bentonite(20%solids) ❑ Other <br /> Grout Placement Methooepumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By riller Ll Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box El Stove Pipe <br /> PUMP KSubmersible❑ 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 /> MINIMMUU A8�-yHOUR <br /> /A DVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953)-7697 <br /> SIGNED / �L.t�(/� /!/�'�' TITLE 0 DATE.?—L <br /> "ISARTMENT SEGONLY >� <br /> Application Accepted By Date V Area A Employee ID# 'S [ � <br /> Grout Inspection By r Date ❑ PECIAL Well Permit <br /> Pump Inspection By ��ti �� t ti Date � L) WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted 3 Service Request# <br /> Dl <br /> -0 I 49) 003 <br /> Cl I rq DI <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />