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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 />NUN-KEFUNDABLE PERMIT <br />SC Received <br />Info <br />(:ALL IZUU) VOJ-fil l FOR INSPECTIONS tAF'IKtS 9 YEAR FROMUATE ISSUED <br />JOL ADDRESS 1 � d <br />I� <br />40 'da <br />/1 <br />CITY/ZIPC` No w eds G ! l]q,57- Z- 7 <br />CROSS STREET 3 <br />T <br />e/ <br />R� <br />APN a!E- -3 OC� <br />PARCEL SIZE - �1' LAND USE APPLICATION # <br />OWNER NAME <br />PHONE / OA, -,e/3 2&,76 '41 <br />OWNER ADDRESS ! 5 �) <br />- 6Gl`eQ <br />de- <br />CITY/STATE/ZIP LodZ`I0 <br />/ C,Aq 062-'10 <br />CONTRACTOR / 3 f%% <br />/�/ <br />/rG <br />PHONE 26/ %72' 2-17 7 <br />CONTRACTOR ADDRESS ) <br />/JO X <br />/ <br />CITY/STATE/ZIP L/klly fz 4"// �, S Cx► l'SZs2 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE �KC-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER &17D7p— EXPIRATION DATE (J�yxeq Zl <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) [-]Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private I(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 E] Replacement Well E] Well Alteration/Modification E] Other <br />E] 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 />ew Pump L] Pump Replacement ❑Pump Repair <br />Raise Well Cas <br />Drilling Method Mud Rotary E] Air Rotary ❑Auger []CableTool F-1 Push Point ❑ Other <br />Proposed Well Depth 320 ft Excavation12 /y in diameter El open Bottom XGravel Pack/Gravel Size in diameter <br />E] Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter T in Thickness/Gauge/ASTM Sched S%%Q Z/ ❑ Steel lastic ❑Stainless Steel ❑Other <br />Grout Seal Depth/Pl ft ❑ Neat Cement (94 lb bag/5-10 gal water) / 'Sand Cement /Z�• 3 sack mix/7 gal water <br />❑Bentonite (20% solids) E] Other <br />Grout Placement Method XPumped ❑ Free Fall El Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller [-]Pump Contractor ❑ Other <br />Concrete Pedestal dimensions: Widthft Length ft Thick .. /,r in F] Christy Box Ll Stove Pipe <br />PUMP [ Submersible ❑Turbine ❑Other HP Pump Set /AD ft Standing Water Level /'w 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 />SIGNED <br />MINIMUI)Q"1I-VOUR ADVANC"OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE eof✓ DATE �?- <br />EPLRTMENT USE ONLY <br />Application Accepted By � in Date ( Z""/ Area ! ` Employee ID# <br />Grout Inspection By !�L'^i S( o4c✓'�.c �-y Date SPECIAL VV@ii FYerMit <br />Pump Inspection By r_taxa ;r., C,' Date j 7 lZ Z ❑ WAIVER ReC@IV@d <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS (.,- tp, QjA �s. •�,zc„(— Yf�li 2 -r -- <br />T <br />m <br />v <br />0 <br />m <br />m <br />VA <br />Pi <br />Codes <br />SC Received <br />Info <br />Amount <br />ash Remitted <br />Date Permit/ Invoice # Well ID# <br />j Service Request # <br />c <br />Z <br />w ., `. <br />EHD 43-06 8101/16 WELL /PUMP PERMIT <br />