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Z <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 <br />Check#/ Amount Date Permit/ Invoice# WeIIID# <br />Cash Remitted Service Request# <br />CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1('YEEAR FROM DATE ISSUED <br />Joe ADDRESS,/0101I <br />�s <br />l . cITY/Zw T1'0CV 95300 <br />2T/r�u(/r�� <br />CROSS STREET W' VG I��/�'N <br />%✓ <br />(^ �.r/��({� <br />APN ✓I �+�J O" 1 PARCEL SIZE�LJ D SE APPLICATION# <br />OWNER NAME 6. 4, <br />6 <br />-7r EI Y PHONE <br />OWNER ADDRESS S2 o <br />r1 U( <br />/� <br />y 61 V CITY/STATE/ZIP T r -, ( t/ s �7 <br />r <br />CONTRACTOR K 1 e i n 1 <br />J �7 <br />v4 -t <br />G u(Q�5 (� <br />ZOq / 7 0 J3 � <br />Jej{A <br />CONTRACTOR ADDRESS <br />0IG'!y1 <br />C,f,_Pr�HON(E j <br />1roo�^ f R4, SE . 1012 CITYISTATE21P J r r/fi/�. 9]j�/�r/ , <br />l <br />'ZOOI <br />SUBCONTRACTOR V "� <br />�� Ili II� <br />PHONE -q6? -7700 <br />SUBCONTRACTOR ADDRESS�I.33 <br />��,�y <br />of J d�' CIT7Y/�STT/ATEIZIP <br />LICENSE 4C-57 C C-61 <br />0 0-09 <br />n Other NUMBER G `may O EXPIRATIONDATE <br />DoMESTIC WELL SAMPLING: U General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />TENDED USE U Domestic/Private L Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />U Public Water System <br />If dff—M from Ownor: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well 0 Replacement Well D Well Alteration/Modification U Other <br />D Monitoring Well(s) #Of wells D Soil Boring(s) aofborings +Geotechnical aa,borinea <br />U Out -Of -Service Well 0 Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />Drilling Method U Mud R ❑ Air Rotary j Auger 0 Cable Tool 0 Push Point 0 Other <br />Proposed Well Depth ft Excavation in diameter I7 Open Bottom O Gravel Pack/Gravel Size in diameter <br />Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel 0 Plastic 0 Stainless Steel ❑ Other <br />Grout Seal Depth it JNeat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix!/ gal water <br />fl Bentonite (20% solids) 0 Other <br />Grout Placement Method Pumped 0 Free Fall U Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By O Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal 11Dimensions: Width It Length R Thick in 0 Christy Box 0 Stove Pipe <br />PUMP D Submersibleo Turbine CI Other HP Pump Set ft Standing Water Level It <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 />EPARTMENT USE ONLY <br />Application Accepted Byz&L Date /y Area �r°'� Employee ID#_IY7 <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By 4 Date ❑ WAIVER Received <br />Soil Boring Inspection By Date ✓� Constructed Well Depth ft <br />COMMENTS <br />PE SC Received <br />Codes Info 8 <br />Check#/ Amount Date Permit/ Invoice# WeIIID# <br />Cash Remitted Service Request# <br />3.1 s <br />M L U24 10 LLIP00 <br />1 <br />36a <br />1 <br />EHD 43-06 ravisad 4/14/16 WELL/PUMP PERMIT <br />