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WELL/PUMP PERMIT <br />SAN MAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT li CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />I <br />JOB ADDRESS '�—i / T �` / i boll''nLK %u CITY/ZIP �{ {iC.�-�/1T f, 1 <br />x <br />Z.- <br />CROSS STREET �� APN 103 1' r^ O U 5 PARCEL SIZE U ° LAND USE APPLICATION # <br />OWNER NAME (,i P �j .� v PHONE <br />OWNER ADDRESS �� 7 yM� V f ��J�%�� `ems CITY/STATE/ZIP 57oc 4 <br />//�a7]a_ <br />CONTRACTOR /" i / , PHONE 77 7�"297S�7 <br />CONTRACTOR ADDRESS �:- i 1 7 o CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE r 57 ❑ C-61 ❑ D-09 ❑Other NUMBER / EXPIRATION DATE 1 <br />DOMESTIC WELL SAMPLING: E[General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE rwomestic/Private ❑Irrigation/Agricultural ❑Industrial E] Water Quality Monitoring El Soil Sampling/Characterize <br />F-1Public 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 /># of boringsin <br />❑ 2017 <br />Monitoring Well ❑ <br />Well(s) # of wells Soil Boring ❑ <br />Boring(s) Geotechnical p 1 <br />❑ervice❑l Plum Replacement El Pump Repair ll ia ell Renewal ❑❑ Raise Well Casing Repair SAN JOAQU/N CO <br />New PumUM <br />WELL CONSTRUCTION Ty pETAL <br />- <br />Drilling Method )d Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point El Other PgRTMEN <br />7. <br />Proposed Well Depth � ft Excavation / Z �V in diameter E] Open Bottom WGravel Pack/Gravel Size ;7r/, -l:, in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Scheds/7a Z ► ❑Steel [Plastic El Stainless Steel ❑Other <br />Grout seal Depth ITI-2ft ❑ Neat Cement (94 lb ba(115-10 gai wafer) j jSand Cement �� 3 sack nib;/7 gal avatar <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method APumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By KDriller El Pump Contractor ❑ Other <br />Concrete Pedestal dimensions: Width ft Length _ft Thick in []ChristyBox ❑Stove Pipe <br />PUMP ubmersible❑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 />_ M1f IMM 24OOIJ7 A�V�A,NCE NOTICE REQUIRED 1707INSPE�CC ONS -PLEASE CALL (209) 95977 <br />DjjPARTMENT USE ONLY <br />Application Accepted By Date �' Area <br />Grout Inspection By V Date <br />Pump Inspection By GLDate <br />Soil Boring Inspection By <br />COMMENTS . )6 f <br />ME <br />Date _ <br />Iq �� <br />0 J (% Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received �Zxo <br />;tructed Well Depth ft <br />T <br />m <br />D <br />0 <br />M <br />m <br />m <br />w <br />to <br />PE <br />Codes <br />SC Receive <br />Info B <br />ec <br />Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />L, W, <br />U <br />34 / <br />jjoC32�5 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />