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I WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />t;ALL ZUU y53-/bUI FOR INSPECTIONS tAt'IKr-%' -1 TEA�/R FROM UAtt 155UtU <br />JOB ADDRESS )—D <br />),Q <br />�/ L <br />WKt W e-�0'e) t- A n � <br />CITY/ZIP L-0 4I / <br />/ 62 / 2 <br />CROSS STREETS <br />1 r I Il5 <br />'402. APN �i PARCELSIZE/. LAND USE APPLICATION # <br />OWNER NAME` <br />�!'�� <br />P" <br />PHONE <br />OWNER ADDRESS <br />/ D <br />km-��) <br />CITY/STATE/ZIP <br />CONTRACTOR <br />arrptoo <br />/�Y GII 6 b/'jelSOn <br />PHONE <br />pr -2 r -;7023 <br />CONTRACTOR ADDRESS q o L <br />TV1 C tn.S'� j'(ti r � <br />/,,% CITY/STATE/ZIP ` -0 <br />%200r <br />/ q 5�2_/ D <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 LI C-61 I1 D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER 66gOOY EXPIRATION DATES13l/Zbzl <br />DOMESTIC WELL SAMPLING: 11 General Mineral/Coliform Bacteria (4391) I_I Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE 1 Domestic/Private I I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />1 Public Water System <br />If different from Owner: Water System Name <br />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) t # of borings F1 Geotechnical # of b gsl <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair ` <br />❑ New Pump I I Pump Replacement ❑ Pump Repair LI Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method I1 Mud Rotary ❑I Air Rotary I I Auger I I Cable Tool I1 Push Point I I Other <br />Proposed Well Depth3 D ft Excavation 6 in diameter I Open Bottom ❑ Gravel Pack/Gravel Size in i6ter <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel I I Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft Neat Cement (94 lb bag/5-10 gal water) 11 Sand Cement sack mix/7 gal water <br />I I Bentonite (20% solids) LI Other <br />Grout Placement Method I 1 Pumped Free Fall ❑ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal I (Dimensions: Width ft Length ft Thick in ❑ Christy Box 11 Stove Pipe <br />PUMP ❑ Submersible[] Turbine 1-1 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 />SIGNED nwu7� TITLEec)/o!' J DATE 6 � �l <br />PA M E N T U E N L Y �/� <br />Application Accepted By f'.�i�s�i► Pate / Area Employee ID# �-r -u-�� <br />C <br />Grout Inspection By Date CI SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Date <br />11 WAIVER Received <br />Constructed Well Depth <br />ft <br />—Service Request# <br />�1�1�� '�.tv ����-�7IfG�/r�►.�►1�i�71�•����1�l 1 Y � <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />