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E <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 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS J <br />CROSS STREET <br />OWNER NAME <br />OWNER ADDRESS !-A h.0 <br />CONTRACTOR 'rA <br />CONTRACTOR ADDRESS/ <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />.j /A,,/ e" Q 9,lCITY/ZIP 4i /0-4-t" /ter <br />/ /� ,►//A1PN ��(f S Iy d PARCEL SIZE LAND USE APPLICATION # <br />�y �t I , � �� 1, J � PHONE <br />LICENSE ,id_C-57 ! I C-61 I I D-09 I I Other <br />NUMB <br />CITY/STATE/ZIP <br />PHONE-? <br />3ff <br />CITY/STATE/ZIP <br />PHONE —I:?- It 2_1 <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE >i(tomestic/Private _! Irrigation/Agricultural I Industrial 1 Water Quality Monitoring I I Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Num VA, .a <br />TYPE OF WORK A New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ' Y " a <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I I Geotechnical #WOMIEF0 <br />ti <br />r 1 Out -Of -Service Well [I Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />q <br />New Pum I Pum Replacement -1 Pum Repair F1 Raise Well CasingS r ®1U <br />WELL CONSTRUCTION N ENVIRO�IN COVN <br />Drilling Method Mud Rotary Air Rotary IJ Auger I_I Cable Tool Li Push Point r]Other��TH 'ENT <br />Proposed Well <br />Depth ~i ft Excavation r L in diameter LI Open Bottom XI"Gravel Pack/Gravel Size Atvdiameter <br />11 Conductor Casing in diametdr / Conductor Casing Depth ft <br />Well Casing Diameter -,(— in Thickness/Gauge/ASTM Sched Zb [ Steel , Plastic I I Stainless Steel ❑ Other <br />Grout Seal Depth U / ❑ Neat Cement (94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />11 Bentonite (20% solids) ❑ Other <br />Grout Placement Methodco<Pumped ❑ Free Fall ❑ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller tJ Pump Contractor I Other <br />Concrete Pedestal ❑Dimensions: Width —� ft Length _ l_ ft Thick =,&_ in I Christy Box I I Stove Pipe <br />au- MP5ubmersible❑ Turbine I I Other HP Pump Set ft Standing Water Level ft <br />HEREBY CERTIFY THAT ! HAVE PREPARED THIS APr'LICAT!ON 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 />MINI8 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)/953-7697 <br />! <br />SIGNED Z- TITLE ��"Ir'� DATE L-4-1 <br />D E A R T M E N T USE ONLY <br />Application Accepted By Date Area Employee ID# V <br />Grout InspectionBy 1�k�1� nom( Date 1 PECIAL Well Permit <br />Pump Inspection By Y rfI$Date i LG ) I I WAIVER Received <br />Soil Boring Inspection.By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />9 1 "AR, WRINNEWAFSOMME120 OR <br />1OMEN=0W1,,1J��►�r`���IDi(0 <br />� <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />