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t 41 WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />IYVIY-RtI-UNUAbLt PERMIT www.sjgov.org/elici EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 41o3' t1,*t;3T L-/CQ'1 RC.t Gbh Ao "4� CITY/ZIP t-(.) I ., `15I� T— <br />CROSS STREET NW bL ,4 , b ()/)/VC APN 0/,-07.-u PARCEL SIZE 6- Z 1 LAND USE APPLICATION # <br />OWNER NAME ee r <br />:/ TiM <br />4kW -S <br />PHONE I S-77 u <br />OWNER ADDRESS riurF/C. X"' <br />?Tr <br />CITY/STATE/ZIPWJo�Qi2rG9P�CA <br />%ZrI-VO <br />Date <br />CONTRACTOR Frt 34(L'(/V& e�or.AAIi <br />❑ SPECIAL Well Permit R CNT <br />Pump Inspection By <br />PHONE 9i6 -7 -f? --72-3/ <br />❑ WAIVER Received �/`/�O <br />CONTRACTOR ADDRESS rYOO k(TUY/J(;/Z <br />X..as}b <br />CITY/STATE/ZIP <br />S)w A44ext %3 Cid 9..r 2 ,-L <br />COMMENTS <br />SUBCONTRACTORICONSULTANT PA"Jcy <br />&Cc'r&-' W'e4C- <br />/e/K::- <br />PHONE 916 , 3 7 / - p V 35, <br />SUBCONTRACTOR/CONSULTANT ADDRESS -:9yY0 064C< -,j k3Ws-Ca",\ <br />CITY/STATE/ZIP <br />WCC —r I�eO�F�^eNZe, CA 9 ( <br />LICENSE )<C-57 ❑ C-61 ❑ D-09 <br />❑ Other <br />NUMBER /yQ r✓GSS <br />EXPIRATION DATE 'L7r�10 <br />BILLING PARTY: ❑ OWNER <br />❑ CONTRACTOR <br />�<SUBCONTRACTORXONSULTANT <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring .19CSoil 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 />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 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 Casino <br />Drilling Method )K -Mud Rotary ❑ Air Rotary 'Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth S`' ft Excavation V in diameter ❑ Open Bottom ❑ 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 ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth S7- ft )"eat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mW7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method D4Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove PiDe <br />PUMP ❑ Submersible❑ 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />T <br />Received hec Amount Da Permit/ Invoice # We A( <br />Codes Info B s Remitted Service Re est # Tti1E <br />J <br />EHD 43-06 6/11/2018 WELL /PUMP PERMIT <br />D PARTMENT USE ONLY <br />Iq <br />Application Accepted 1 <br />Date <br />Z(iZI <br />Area Employee ID# <br />Grout Inspection By <br />Date <br />❑ SPECIAL Well Permit R CNT <br />Pump Inspection By <br />Date <br />❑ WAIVER Received �/`/�O <br />Soil Boring Inspection By <br />Date /� y3 <br />-may/ <br />Constructed Well Depth At®Vf, n /, ft„O <br />COMMENTS <br />'SAA1` 21 <br />Ll—Ely ION <br />PE Sc <br />Received hec Amount Da Permit/ Invoice # We A( <br />Codes Info B s Remitted Service Re est # Tti1E <br />J <br />EHD 43-06 6/11/2018 WELL /PUMP PERMIT <br />