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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 PE//RR�MIT�^ `/_CALL 209 953--76/97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,/�Jr{ <br /> JOB ADDRESS �JJ /jJ,/ ' �lr' CITY/ZIP <br /> 7 / 1�rn��h �a 9SZ z 7 Sm <br /> 'l <br /> L/, �7 n <br /> CROSS STREET /7 T/C/I/7S IAC/ APN L/I - 7) PARCELSIZE LAND USE APPPPLIICCATION#�,( `�/ p <br /> OWNER NAME el 1 /gal L� PHONE %�[/ �,/ 2G16 <br /> OWNER ADDRESS Ig,�fG j; RkleD ne CITY/STATE/ZIP / AZA' X-f2 7o <br /> CONTRACTOR _ /G 3I�J �Q/�a///.Y�//JC PHONE L{// 77,7 - Z�'76­7 <br /> CONTRACTOR ADDRESS�D� /7Z 9 CITY/STATEIZIP P/�iller�� ///.�js 41 452ST► <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATErZZIIrP e <br /> LICENSE C-57 ❑C-61 E]D-09 C]Other NUMBER.Z&AP7!/ EXPIRATION DATE (J4/ <br /> DOMESTIC WELL SAMPUNG:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)[]Arsenic(4393) r i <br /> INTENDED USE Pbomestic/Private ❑Irrigation/Agricultural ❑Industrial []Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name L;CntaCt Name or Phone um r <br /> TYPE OF WORK IgNew Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Wells) #of wells []Soil Bodeg( ) ❑Geotechnical s #of borings #of borings <br /> E]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 El Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth 3Z0 It Excavation /1-XV in diameter ❑Open Bottom ?Gravel Pack/Gravel Size in diameter <br /> ElConductor Casing in diameter / Conductor Casing Depth / It <br /> Well Casing Diameter ev in Thickness/Gauge/ASTM Schad,jDQ ZI ❑Steel /$Plastic El Stainless Steel ❑Other <br /> Grout Seal Depth /,40 It []Neat Cement(94 Ib bagl5-10 gal water) ❑Sand Cement ©' sack mW7 gal water <br /> ❑Bentonite(20%solids) []Other_ k, Sia <br /> Grout Placement Method XFumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL installed By firDriller El 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,T Pump Set ft Standing Water Level / D- 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)-9953-7697 <br /> e <br /> SIGNED TITLE "ei .fq�G/(/IE/tj/ DATE <br /> l <br /> '14SA UI <br /> T <br /> T <br /> DEPARTMENT Y /f <br /> Application Accepted B r ' Data 1710 Z-/fArea `-f" (l Employee ID# <br /> Grout Inspection By /� r Date q7 -ZOV ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection��Byp1� Date _ Constructed Well Depth ft <br /> COMMENTSA ��[��/L. <br /> PE SC Received C Amount Date Permit/ Invoice# Well ID# <br /> Codes Info gj,, C-as-fi- Remitted Service Re uest# <br /> SI 7A b I 2 <br /> o LHP00 <br /> 5� W <br /> EH043-06 8/01/16 WELL/PUMP PERMIT <br />