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e WELL/PUMP PERMIT <br /> SA14 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 /> .2f-6 � #A1 v l` 7r'C L - q 5 J 32 m <br /> JOB ADDRESS .LST—T— T�-+9-rLZT--��z' CITY/ZIP ti a <br /> CROSS STREET M O n t7 APN Z Dl�c/ PARCEL SIZE LAND USE APPLICATION# 0 <br /> AIW �� v En <br /> PHONE <br /> OWNER NAME y <br /> OWNERADDRESS i CITY/STATE/ZIP 2, <br /> L� rreNcv-i , �V Q i J h� /S[7 PHONE 2.� i —`�.7— �GL <br /> CONTRACTOR �) /1 1 t / /� <br /> CONTRACTOR ADDRESS 1 ✓ 2- �1 jl,,S 1 f I�^/ "z CITY/STATE/ZIP -f_j/ �[_ZI Z <br /> r <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 57 ❑ C-61 ❑ D-09 ❑ Other NUMBER (bio`I GU EXPIRATION DATE r <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial CI Water Quality Monitoring XSoil 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 Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical / Q #of borings <br /> [I Out-Of-Service Well 11 Out-Of-Service Well Renewal ❑ on Cross-Cection Repair J <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary XAuger ❑ Cable Tool I Push Point ❑ Other <br /> Proposed Well Depth IS ft Excavation 6 in diameter I I Open Bottom Ll Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched a Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) I l Other 4 0C <br /> Grout Placement Method ❑ Pumped ❑ Free Fall Xother I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I-I Other <br /> ❑ Concrete Pedestal I]Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine I 1 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 /> MI ]M4-UM 48 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) J953-7697 <br /> SIGNED � '✓yj� TITLE ea il0�/5 DATE 1///%Z 2_01S <br /> t <br /> I <br /> EP RTMENT U E O LY <br /> Application Accepted By Date Area Employee ID#,�W� <br /> Grout Inspection By Date f] SPECIAL Well Permit <br /> Pump Inspection By Date El WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ®AYAl EAUT <br /> PE SC ReceivedChec Amount Permit/ <br /> ,rpipdes Info B _-Cash emitted Date Service Request# Invoice# WII ID# <br /> SAN JO) QUIN COUNTY <br /> -- <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />