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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 �� ��5 l_tV ad CITY/ZIP —7 o y q53 7 / m <br /> r te- D <br /> CROSS STREET J AP'N A <br /> 1 c-V�D�i �C 1 PARCEL SIZE �O✓LAND � <br /> USE \ 11�APPLICATION# A <br /> OWNER NAME N �, PHONE OCA .) Ci � <br /> OWNER ADDRESS )15gI 11L1QwiPA;n► V.ZEuJ ;zJ CITY/STATE/ZIP <br /> CONTRACTOR Pz?-JYY � PHONE <br /> CONTRACTOR ADDRESS 4t,�W -,-ea4b 1429r* RBI CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: ' General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE �X Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characteriza � <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK X New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #+of gg y 2019 <br /> ❑ Out-Of-Service Well 11 New Pump ❑ PumpReplacement ❑ Pump Repair a Well Renewal 11 Raise Well Casin11 Repair SEN OAQUVI /H COIJ <br /> ItNWELL CONSTRUCTION LTH pEPARTrAL <br /> Drilling Method KMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 11 Other MEIN <br /> Proposed Well Depth 5&) ft Excavation (Z //,/ in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size 3�G, in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter L in Thickness/Gauge/ASTM Sched 5012 17 11 Steel X Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) 0(Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method K Pumped ❑ Free Fall ❑ Other I] Retardant/Accelerator(name) <br /> PEDESTAL Installed By 79 Driller [1 Pump Contractor ❑ Other / <br /> Li Concrete Pedestal ❑ _fDimensions:Width ft Length ft Thick z--in ❑ Christy Box ❑ Stove Pipe <br /> PUMP A Submersible❑ Turbine 11 Other HP__Z Pump Set ft Standing Water Level U,A 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 COMP SATION LAWS. <br /> MINI HO V E NOTICE REQUIRED FOR INSPE TIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE L DATE ' <br /> DEL-) <br /> RTMF_ NT USE NLY <br /> Application Accepted ByDate Area Employee ID# <br /> Grout Inspection By Date 51 ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS / <br /> t <br /> Alrij <br /> PE SC Received Che Amount Permit/ <br /> Codes fo B ash a itted Date Service Re uest# Invoice# Well ID# <br /> l <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />