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1 <br />9 1� y <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTOF VENUE-STOCKTON CA 95205 - (209) 4683420 <br />NOWREFUNDABLE. PERMIT �t /cCCALLL 209 953-7697 FOR INSPECTIONS T EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS V `-i � V vx t ray s-31 7 <br />1 <br />CROSS STREET �JC'i�Y C..C.� L, P21 AL/PJ�N W ��J�� PARCEL SIZE37 LAND USE APPLICATION # <br />OWNER NAME-(/ w �! e_ L� PHONE /♦ �Al'� ^ <br />OWNER ADDRESS �O �+ — 1NI !/ CITY/STATE/ZIP <br />CONTRACTOR KI�IhE�1/yylyy�'�k i��C� , PHONE V-12 <br />J <br />CONTRACTOR ADDRESS.(al f IArAovi" Rd. Sbe/, 100 CITY/STATE/zip t7C A <br />SUBCONTRACTOR \ I N Dr; Iti `�1' �{ L ��,PyHONE (Loo'. 46 q —3,700 <br />SUBCONTRACTOR ADDRESS 1133 I l� aa- U-1 s 1T�_ CITyY/S�TATE/ZIP WIk Iq C U 6. L <br />LICENSE V C-57 El G-61 ❑ D-09 LI Other NUMBER W © EXPIRATION DATE :)0 <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochlaropropane (4392) 0 Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Aiteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings / Geotechnical I of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />n New Pumo n Pumo Reolacernent ❑ Pumo Repair ❑ Raise Well Casino <br />Drilling Method 4 Mud Rotary ❑ Air Rotary j Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft V Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/`7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method 4 Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dlmenslons: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible[] Turbine ❑ 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 H ADVANCE NOTICE REQUIRED FOR <br />S TIO S - PLEASE CALL (209 9193-7997 <br />SIGNED TITLE ./ .i %/ �C/ DATE <br />N <br />M <br />0 <br />m <br />H <br />Pump Inspection By /jy�--�I� Date <br />Soil Boring Inspection By ���"r+i + Date <br />COMMENTS <br />'-1 WAIVER Received <br />Constructed Well Depth it <br />EHD 43-06 revised 4/14/18 WELL /PUMP PERMIT <br />