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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 [ / r�I1�/ L// CITY/ZIP m <br /> D <br /> CROSS STREET A] c1 APN %O �/ `' PARCEL SIZE r LAND USE APPLICATION# M <br /> - <br /> cn <br /> OWNER NAME e��t C J ��/1 /y PHONE <br /> OWNER ADDRESS /�/y ,(f[\�r 1✓� �� CITY/STATE/ZIP t, <br /> CONTRACTOR L`1 d- \ G1-1 iT r �/?�CL G L1 PHONE � 3 7—�/}/ <br /> CONTRACTOR ADDRESS / �jL �I CITY/STATE/ZIP Cam/ '�J I✓1-21, f h <br /> SUBCONTRACTOR � 6 �f 1 ( 7y� r� (n✓r PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 C 51 ❑ D-09 Other NUMBER Lr i 1 f EXPIRATION DATE -2-.J <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE 'U Domestic/Private><rrigation/Agricultural I I Industrial Water Quality Monitoring 1 1 Soil Sampling/Characterization <br /> Public Water System A&1 - <br /> �r <br /> If different from Owner Water System Name Contact Name or Phone Number T` <br /> TYPE OF WORK 1° ew Well C1 Replacement Well ❑ Well Alteration/Modification ❑ Other VGA <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring #of borings s) I i Geotechnical —Mpt borings <br /> ❑ Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair SAN a J 2019 <br /> ICJ New Pump ❑ PumpReplacement El Pump Repair ❑ Raise Well CasingBOA <br /> WELL CONSTRUCTION Hk/>Lr HOF 'g ON,►f UN Ty <br /> Drilling Method�ud Rotary ❑ Air Rotary I I Auger -I Cable Tool I_i Push Point I i Other RT���� <br /> Proposed Well Depth� ft Excavation l in diameter I I Open Bottom ravel Pack/Gravel Size in diameter <br /> 11 Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched rY�i I I Steel �'lastic I I Stainless Seel Other <br /> Grout Seal Depth <7-�_ft I I Neat Cement(94 Ib bag/5-10 gal water) >Kand Cement l L/ �' sack mix/7 gal water <br /> ❑ Bentonite(20%solids) I Other <br /> Grout Placement Method ;,✓Pumped Free Fall Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller 11 Pump Contractor I I Other <br /> LiConcrete Pedestal I IDimensions:Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br /> PUMP -%el�'SubmersibleI I Turbine 1 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95 11 3-7697 <br /> vJ/ a -r-'-/a <br /> SIGNED /` �c.G�- TITLE ,U.4 DATE <br /> C. <br /> f ; <br /> -(DEPARTMENT YSE ONLY <br /> Application Accepted By Date 4dl Area 4f 14 1, Employee ID# `� <br /> Grout Inspection By Date 2 17 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received 16hecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B s 4 Remitted Service Request# <br /> 'l <br /> YX <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />