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& WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />?J(iN-REFI imnARl F PERMIT rAi I ignm 953-7897 FDR INSPFrTInNS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ✓�� V� CITY/Zip <br />CROSS STREET /VG%�U 1 APN ' 2(A7PARCELSIZE f L+_7 LAND USE APPLICATION # <br />OWNER NAME `Oil <br />PHON��% <br />OWNER ADDRESS ® l CITY/STATE/ZIP �D <br />CONTRACTOR ai4kK W tkt r, � t LY ,•.vx ,PAHO,N,, JD0� V - &104 11L/""1 <br />CONTRACTOR ADDRESS C) ! CITY/STATE/ZIP-;21 <br />SUBCONTRACTOR 4� PHONE <br />SUBCONTRACTOR ADDRESS CIITYTY/STATE/ZIP <br />FERN I <br />LICENSE C-57 I_I C-61 I I D-09 I Other NUMBER `' ` ' EXPIRATION DATE Z C) <br />DOMESTIC WELL SAMPLING: I I General Mineral/Coliform B ( ibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE X Domestic/Private I I Irrigation/Agricultural CI Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization <br />I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number /1 <br />TYPE OF WORK XANew Well I I Replacement Well I I Well Alteration/Modification ❑ Other 1 <br />1 Monitoring Well(s) # of wells I I Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />1 Out -Of -Service Well I I Out -Of -Service Well Renewal F1 Cross -Connection Repair J4 <br />11 New Pum I I Pum Replacement r -I Pum Repair F1Raise Well Casingp <br />WELL CONSTRUCTION FNH�r IRCNf?O/V <br />Drilling Method Mud Rotary Cl Air Rotary [ ] Auger CI Cable Tool ❑Push Point nOther <br />LMEN �N <br />Proposed Well Depth !�ft Excavationes in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in nil. <br />ir <br />I-1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter -L—in Thickness/Gauge/ASTM Schede F1Steel )(Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft I i Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) I I Other <br />Grout Placement Method XPumped 1-1 Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By 1 1 Driller Pump Contractor 11 Other <br />I I Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in I I Christy Box ❑ Stove Pipe <br />PUMP 11 Submersiblerl Turbine 17 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 COM ENSATION LAWS. <br />�IN`H�1­10��NCE NOTICE REQUIRED F R INSSP1µ1C1'CTIONNS - PLEASE CALL (209) 9 3--/769 <br />SIr:NF:n TIT[ F "N1' 1 1 1-�, DATF I I/] f2 O <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />ur <br />PA TMENT SE ONLY <br />Aiam <br />Application Accepted By Date 0 Area mployee ID# <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS A)b _W <br />Date <br />I 1 WAIVER Received <br />Constructed Well Depth <br />ft <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />Service Request # <br />�r ��_ �`i' w *�I_%MZ�d IIPFAM <br />1 10017 �!��1 i� : ' 9MII%1T107M <br />►�i,' ��rlli'i�I/.�S1�C ��ir�►l r. <br />EO' 0 1 MMM <br />� <br />�1.rjL7.ti�11/� 0 0 0 1 Li E Ll ;d I kwl 6 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />