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WELUPUMP 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 .7i(o60 \i 0(n M ct C- �— i'1-p CITYZP (-�,CA m <br /> l� t } _ M <br /> CROSS STREET �-�� T p <br /> PARCEL SIZE J hI.N GA\PN V I' .�7 � LAND USE APPLICATIONN# <br /> OWNER NAME F- `16N r LJ tilt 1 J PHONE — I <br /> ra <br /> OWNER ADDRESS S A M C. CITY/STATE/ZIP AA <br /> e— <br /> CONTRACTOR Q 1 1 1-C y fQ r\ 11 1 r)I /PHONE J& 1Q <br /> —,77 0 71 <br /> CONTRACTOR ADDRESS �'l.) ll U x CRY/STATE/ZIP 6711 I�, L A 1 5GJz <br /> 2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE �,<C-57 �C-61 D-09 Other NUMBER 23/ R - 7 <br /> EXPIRATION DATE / —!�2 0 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)11 Arsenic(4393) <br /> INTENDED USE XDomesticlPrivate J Irrigation/Agricultural a Industrial Li Water Quality Monitoring :I Soil Sampling/Characterization <br /> ❑PuMic Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ,New Well I I Replacement Well ❑Well Afteration/Modification I I Other <br /> L Monitoring Well(s) #of wells ❑Soil Boring(s) sof borings Geotechnical s of borings <br /> ❑Out-Qf-Service Well El Out-Of-Service Well Renewal 11 Cross-Connection Repair <br /> ew Pum I I Pump Replacement D Pump Repair I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)/Mud Rotary r7 Air Rotary ❑Auger i7 Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth .505 It Excavation I A in diameter a Open Bottom ;KGravel Pack/Gravel Size 1/4 _ in diameter <br /> J Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM SchedC I�bQ 11 Steel �4 Plastic ❑ Stainless Steel i'Other <br /> Grout Seal Depth 160 it I 1 Neat Cement(94 Ib bag/5-10 gal water) >4 Sand Cement I C. sack mix/7 gal water <br /> n Bentonite(20%solids) r,Other <br /> Grout Placement Method A Pumped ❑Free Fail I_I Other I Retardant/Accelerator(name) <br /> PEDESTAL Instad By Driller Pump Contractor F, Other <br /> 1 Concllerete ede11stal❑Dimensions:Width-A—ft Length It Thick in I i Christy Box Stove Pipe <br /> PUMP Submersible I Turbine r Other HP 0 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS-PLEASE CALL(209)953-7697 <br /> `J q <br /> SIGNED -L�/-/`^"ms µ TITLE \l a I� rC-S DATE <br /> d r RPA yftc�r <br /> e C <br /> FP 2 <br /> U r �RQovC 2419 <br /> O O(j <br /> Ty 0 p31 ����)Y <br /> TIT- <br /> �A TMENT U E qNLY <br /> Application Accepted By Areae Employee ID# <br /> Grout Inspection By Date a 1�c'� �I ❑ SPECIAL WBII Peffnit <br /> Pump Inspection By- t Date.' i'111e' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Weil Depth ft <br /> COMMENTSo�bt �6Y7 c St t�,l^�1(� t "mac 4 1/ - <br /> PE SC Received Che Amount pate Pertntt/ Invoice# Well ION <br /> Codes Info Remitted ervice Request# <br /> Z_ <br /> ' I r <br /> EHD 43-06 revised 4114/18 WELL/PUMP PERMIT <br />