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sr,nl�u� Scan i1Irl III kM <br /> • WELL/PUMP PERMIT <br /> SAN JO;.QUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> a NONREFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S E• L l- P-i CITY/ZIP 'FSCi; I61 m <br /> 6 D <br /> /,ROSS STREET 4LAJ� A ! APN D PARCEL SIZ •O LAND USE APCPLICATION# A <br /> (OWNER NAME PAY Aw\APy� PHONE ya G' ���� � <br /> OWNER ADDRESS 36 6 r:) L-t+>✓ P-4 CITY/STATE/ZIP &C[1 �} P <br /> CONTRACTOR Mattteli(t f 6 \ � k('• PHONE Z �LCD <br /> CONTRACTOR ADDRESS `I ` A I}')C-r} ' CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -�<C-57 El C-61 F]D-09 ❑Other NUMBER 6A6 EXPIRATION DATE y " 36— 147 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural []Industrial E]Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK >rNew Well Replacement Well ❑Well Alteration/Modification El Other <br /> [I Monitoring Well(s) #of wells E]Soil Boring #of borings s) ❑Geotechnical #of borings <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 MethodNVMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom NGravei Pack/Gravel Size in diameter <br /> F1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter f in Thickness/Gauge/ASTM Sched 256 ❑Steel—>(Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depthft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By [:]Driller 3kump Contractor ❑ Other <br /> ❑Concrete Pedestal EI)imenslons:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑Turbine E]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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR (INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED �`� TITLE /✓/-4 i Ve DATE /6- 1-7 <br /> V� <br /> Q � <br /> 7 <br /> tt <br /> Ji <br /> v O' <br /> b ®° <br /> 11 1 <br /> ir <br /> / f <br /> m "A J <br /> (Ir Aft. lR C <br /> D n A <br /> EP RTMENT U E ONLY <br /> Application Accepted B Date �� Area Employee ID# V <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS O ' Z- '�- <br /> G� .4 O/ tX-�'/c��' Vii✓ <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes 10fo By Cash emitted Service Request# <br /> hr -2 1 V �1 V <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />