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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 /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB-ADDRESS /�/`(/ �1� �J✓G��G Xell _ CITY/ZIP (i/✓ �/J/$ L�i4 G Z m <br /> i�ir�s �/ ,) X v <br /> CROSS STREET APN V L�l I� �� � PARCEL SIZE / � y LAND USE APPLICATION# _ <br /> Bob !gam!/ PHONE <br /> Cn <br /> OWNER NAME PH <br /> _O`NE/ %�y �/ 20�7/ � <br /> OWNER ADDRESS /Q <br /> CITY/STATE/ZIP ,( �//' � �352yo <br /> CONTRACTOR /�3� ��/ ��1Gjp/�J� PHONE L,�J"//� 772 Z7s--7 <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP�/���iGt/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP d <br /> LICENSE OC-57 ❑C-61 ❑D-09 [I Other NUMBER Z9I7O7f EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE �Xbomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑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 �41\lew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings [IGeotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement E]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary El Air Rotary [-]Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth .32D ft Excavation in diameter [-]Open Bottom I Gravel Pack/Gravel Size31it. in diameter <br /> [-]Conductor Casing in diameter / Conductor Casing Depth T ft <br /> Well Casing Diameter 4;, in Thickness/Gauge/ASTM Sched,SpQ Z/ []Steel PTIastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth �� ft El Neat Cement(94 lb bag/5 10 gal water) ❑Sand Cement /(i' sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other � z <br /> Grout Placement Method Free Pum ed Fall p ❑ ❑Other ❑Retardant/Accelerator(name) — <br /> PEDESTAL Installed By FNMriller ❑Pump Contractor ❑ Other <br /> Concrete Pedestal dimensions:Width��ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP� Pump Set ft Standing Water Level ft <br /> I HEREBY CE IFY 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE ,�yGi?'rs+/t� DATE �/- Zd <br /> - l <br /> dc)AC <br /> UlAf <br /> ]EI <br /> � T <br /> Tn E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 4: Date I 171074 Area (1 Employee ID#_ <br /> Grout Inspection By Date —�-202/ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS Id✓ �,:Eg(X T 6AI SI— _ -- <br /> PE SC Received ,Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> i G 517 W P D04 2 <br /> -L f t <br /> 2 W0 010 L_ 0.01 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />