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`, WELL/PUMP PERMIT c <br />SAN MAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT /i CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS I `''' r7—/ / 1,/ 'k, tU! IIn/�Ly� ` C <br />U3 ITY/ZIIP S{ V�� ll <br />CROSS STREET ,_ee,4e,<_ APN / ' O U PARCEL SIZE U ` �I LAND USE APPLICATION # <br />OWNER NAME P PHONE / <br />OWNER ADDRESS L'�! CITY/STATE/ZIP�n5� PHONE.4 - 7 72-,�5� <br />CONTRACTOR /" / - I ' � <br />CONTRACTOR ADDRESS / 1 /�►' <br />/G� i 7 + CITY/STATE/ZIP y((J/� y �//AL1 \ l d' • C! J GJ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 7 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: ElGeneral Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE 70omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterizwl� <br />F-1PublicWater System <br />If different from Owner: Water System Name Uontact Name or Fhone um er <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑Other <br />❑❑# of borings ❑ 2017 <br />in Monitoring #of wells Soil Geotechnical 1 <br />❑New Out -Of -Service ell E] Pum Replacement El Pump Repair a Well Renewal ❑❑ Raise Well Casing <br />Repair SAN JOA <br />urnQVIN CO <br />WELL CONSTRUCTIONTH DEP TAL <br />Drilling Method )4 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point E] Other MTMEN <br />Proposed Well Depth i ft Excavation i Z y in diameter E] Open Bottom Gravel Pack/Gravel Size 711<.e in diameter <br />❑ Conductor Casing in diameter / Condduc/u��cttorr �Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Schecl�, 7`� JJ _ / ❑Steel F'APIastic E] Stainless Steel ❑Other <br />Grout: Seal Depth /to ft ❑ Neat Cement (94 Ib ba(115-110 gai water) �4Sand Cement �� 3 sac;% rr,;,' 7 ya! uo ar <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By X Driller ❑ Pump Contractor ❑ Other <br />Concrete Pedestal ❑pimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HP Pump Set &X2ft 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 />DJJPARTMENT USE ONLY <br />Application Accepted By Date % Area_ <br />Grout Inspection By Date y ❑ <br />Pump Inspection ByMk� AA4Date ❑ <br />Soil Boring Inspection By <br />COMMENTS _ )< f t <br />;ia <br />M <br />Date _ <br />T <br />m <br />D <br />0 <br />M <br />m <br />m <br />Cn <br />Cn <br />L' / C1 e� Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received �> <br />cted Well Depth 4 ft /4 <br />PE <br />Codes <br />SC Receive <br />Info B <br />eck# <br />Cash <br />Amount <br />Remitted <br />Date Permit/ Invoice # Well ID# <br />Service Request # <br />436( <br />rJ <br />'scl <br />/17 epi , 5 - <br />L1 19 I <br />W-4 <br />S <br />y <br />/ / .—d\ <br />IA 1 0 <br />EHD 43-06 8101/16 WELL /PUMP PERMIT <br />