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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 <br /> ^ `/_CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z,6z& 'r ,/�Jr{/jJ,/L�/G �lr' CITYIZIP m 7 / 1�rnG�h �a 9SZ z 7 <br /> Q LL/, n <br /> CROSS STREET XlktI/7S }7I�C// APN L/1 � 73�PARCELSIZE LAND USE APPPPLIICCATION# �Jw`�/ p <br /> OWNER NAME ebb �IiGlI PHONE %�[/ Z-11 J rn, <br /> OWNER ADDRESS - - � Rklee n _ CITY/STATE/ZIP._�f�/ Z -952`70 <br /> CONTRACTOR /0 3,w r/,QI�I� ' /17� _ PHONE Z2 772 - Z'�'75 7 <br /> CONTRACTOR ADDRESS /7Z9 CITY/STATE/ZIP zw—leX 5 V22%9 -,If�IS2SZ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER,fD/717!/ EXPIRATION DATE 441 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)[]Arsenic(4393) r i <br /> INTENDED USE Obomestic/Private ❑Irrigation/Agricultural ❑Industrial []Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name L;OntaCt Name or Phone um r <br /> TYPE OF WORK IgNew Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Wells) #of welis []Soil Bodeg( ) ❑Geotechnical s #of borings #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump 0 Pump Replacement E]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUC ON <br /> Drilling Method AMud Rotary ❑Air Rotary []Auger []Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 3Zo ft Excavation /1-XV in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> El Conductor Casing in diameter / Conductor Casing Depth / ft <br /> Well Casing Diameter ev in Thickness/Gauge/ASTM Sched,jDQ Z/ ❑Steel /$Plastic El Stainless Steel ❑Other <br /> Grout Seal Depth1,ft []Neat Cement(94 lb bag15-10 gal water) ❑Sand Cement 1116zg sack mW7 gal water <br /> ❑Bentonite(20%solids) []Other_ Es,, <br /> Grout Placement Method XFumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL installed By 'Driller [I Pump Contractor ❑ Other <br /> Concrete Pedestal Epimensions:Width �_It Length JIT ft Thick in El Christy Box ❑Stove Pipe <br /> PUMP 16 Submersible❑Turbine ❑Other HP, Pump Set ft Standing Water Level / �— ft <br /> I HEREBY CE IFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIM OUR AD NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> // <br /> SIGNED410 TITLE GrU .fq�G/(/IE/tj/ DATE <br /> l <br /> A L11 <br /> Bq T <br /> T <br /> 1 DPARTMENT VSY QNLY <br /> Application Accepted B '! r ' Date (( 7-0 Lt Area Employee ID# <br /> Grout Inspection By /� r Date q7j —2.02/ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date _ Constructed Well Depth ft <br /> COMMENTS Al517� — <br /> PE SC Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Info as Remitted Service Re uest# <br /> S! 7A b I 2 <br /> o He 00 <br /> zj 5v W <br /> EH043-06 8/01/16 WELL PERMIT <br />