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' WELL/PUMP PERMIT K /° <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON GA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />L;ALL ZU9 953-7597 INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />�L�//� <br />JOB ADDRESS 9 6 � a / <br />rF�OR <br />i c /9 x/ r -2 1,/ L- (2 `�,/ � . <br />CITY/ZIP T ['�— vk c `�. <br />C? 1-4 <br />CROSS STREET 1XIA L 1�£2/d <br />l� 1 �(� APN 0i <br />PARCEL SIZE U Y <br />LAND USE APPLICATION # <br />OWNER NAME L / I <br />s `� <br />rc►Jas <br />2 ' ! <br />PHONE - 0 <br />) <br />OWNER ADDRESS � <br />t�G� <br />�Jt7T <br />�� ��� Z ✓ <br />C <br />CITY/STATE/ZI M <br />C <br />-� <br />CONTRACTOR/ G <br />' <br />/-�(i� W�/� <br />PHONE 4b% <br />J �'1��CJ <br />CONTRACTOR ADDRESS <br />Za,77 /,-7 re � � f I J <br />CITY/STATE/ZIP <br />7- /9 -q (-` / <br />q 530 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE T�C-57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER cI S 3 ('- J 6 EXPIRATION DATE J 3 ) - / f.. <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE [domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring El 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 Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />F1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />Mew rump Lj rump Kepiacement U Hump Kepair Lj Kalse vveu Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑Mud Rotary ❑Air Rotary [-]Auger ❑Cable Tool F] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom ❑Gravel Pack/Gravel Size_ <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched [:]Steel❑Plastic El Stainless Steel E] Other <br />in diam <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) [-]Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal ❑pimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP XSubmersible ❑Turbine ❑Other HP ( , '�'— Pump Set 16 0 ft Standing Water Level j&;0 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. 1 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 />c <br />T <br />m <br />D <br />0 <br />v <br />m <br />m <br />w <br />DEPARTMENT USE ONLY / <br />Application Accepted By 1.(fV� /y Date �' J u') 0 Area / G� Employee ID# , % Iy1 t'!J` <br />Grout Inspection By Date 1 �1 ❑ SPECIAL Well Permit <br />Pump Inspection By Date U WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />ft <br />PE SC Received Check#/ <br />Codes Info By Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />y3Y S <br />O it1p 7 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />