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t 1, <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE "P�E�}RMIT t� C:ALL 209 953-7697 FOR INSPECTIONS L�-EXPIR`EES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ILL- ('j�p �7 K �J l i• r L'+C1C� CITY/ZIP-�r^,1,�-�-�� <br />CROSS STREET Ii ✓ cki u� }/G (. APN ,IrI�4) VCo� - t PARCEL SIZE ,LAND USE APPLICATION # <br />OWNER NAME I -1\\C O V, j0'I/1' ` \ C �C(''1Y `(tJ'� \ \�J�� �� L V �N/E L7 -P <br />OWNER ADDRESS VISTATpZIP ;j\CC•^��`i1�`j�_ <br />CONTRACTOR ``\�t/+ y / ,,PHONEl./C' -' \ J LLj <br />/vj <br />CONTRACTOR ADDRESS 'I 17 7 CJ` LI_C-{-� UrS I D(! \ - CITYISTATEIZIP V0 I � = L 1 <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS 7CIITIYIST�ATEIZIP <br />LICENSE )(C-57 J C-61 D D-09 ._ Other NUMBER -72 L610L4 <br />0L4 ExPIRATION DAII <br />DOMESTIC WELL SAMPLING: , General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) = Arsenic (4393) <br />NTENDED USE Domestic/Private C Irrigation/Agricultural - Industrial F' Water Quality Monitoring 'Soil 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 Iii Well Alteration/Modification D Other <br />MonitoringWell(s) #of wells DSoil Boring(s) #of borings +'Geotechnical ( #ofbodngs <br />Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair <br />❑ Kalse Well <br />Drilling Method xMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Push Point _ Other <br />Proposed Well Depth??0_ft Excavation S in diameter Open Bottom C Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched a Steel Plastic - Stainless Steel Other <br />Grout Seal Depth 7t7 ft Neat Cement (94 Ib bag15-10 gal water) Sand Cement sack mix77 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method XPumped Free Fall _ Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller i Pump Contractor Other <br />Concrete Pedestal .Dimensions: Width ft Length ft Thick in a Christy Box Stove Pipe <br />PUMP Submersible I Turbine i 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 />A"IMUM 44888 HC ADVANCE NOTICE REQUIRED FOR INSP, CT O/1NS-/PL;JE!AS/E CALL (209) 1953-7J697 <br />SIGNED _ — 11 -/� TITLE "t( : �II (,�'.I V 1_ek 1 DATE 1'y --{ <br />T <br />m <br />D <br />v <br />z <br />(A <br />ENT <br />VE® <br />2018 <br />COUNTY <br />ENTAL <br />,RTMENT <br />EHD 43-06 revised 4/14/18 <br />jWjWMrAM <br />WELL /PUMP PERMIT <br />PA MENT US ONLY <br />Application Accepted By <br />ate <br />Area Employee <br />Grout Inspection B <br />Date <br />❑ SPECIAL Well Permit <br />Pump Inspection ByFRUTT <br />Date <br />❑ WAIVER Received <br />Sail Boring Inspection B <br />Date <br />Constructed Well Depth <br />ft <br />COMMENTS <br />J ZIL IN <br />0 EVIL Eli 0 jr <br />EHD 43-06 revised 4/14/18 <br />jWjWMrAM <br />WELL /PUMP PERMIT <br />