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.Q ✓ 3 <br />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 . j_-XF'IKtS 1 YEAR FROM UATE ISSUED <br />CROSS STREET AAAPLN IG I d U�y PARCEL SIZE �LAND <br />©USE <br />APPLICATION # J7/ <br />OWNER NAME /1—A �LZ/yf/�N�v <br />a1 n V KHONE" `% / 067 <br />OWNER ADDRESS �J�%� CITY/STATE/ZIP 131-371-0 <br />�7�� r S <br />CONTRACTOR / �,/ D(/,Golhtx S /A�/,,6/./�L a�/7� PHONE / 3 3�V <br />CONTRACTOR ADDRESS ?1ze GIJI�-Gl7x� / CITY/STATE/ZIP _ p0,►w <br />SUBCONTRACTOR—� <br />SUBCONTRACTOR ADDRESS—` <br />CITY/STATE/ZIP <br />PHONE <br />LICENSE X-57 ;A§t1 ❑ D-09 ❑ Other NUMBER l EXPIRATION DATE / ✓/ <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑Other <br />[:]Monitoring Well(s) #of wells E] Soil Boring # of borings s) []Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump Wum <br />P <br />Raise Well Casi <br />Drilling Method E] Mud Rotary E] Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched E] Steel ❑Plastic E] Stainless Steel ❑Other <br />in diameter <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ubmersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CE TIFY 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 />Ml=H A VANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 95 -7697 <br />SIGNED �- TITLE DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By h Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS I <br />Date <br />T <br />m <br />D <br />v <br />0 <br />m <br />m <br />co <br />ur <br />Area 'f CI `) EmployeeID# ZSe-a�id <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE <br />Codes <br />SC <br />Info <br />Received Check#/ <br />By Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Re ue # <br />LILT ) <br />%7 <br />03-7 11ql <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />