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r <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE 7MIT <br />L;ALL LUy <br />UOJ-tbUf FOR INSPECTIONS tA,PI�KtS 1 FROM DATE ISSUED <br />JOB ADDRESS �l�-19 <br />u <br />I' // w G �' <br />YEAR <br />CITY/ZIP 21 Kly�/"� L�r <br />lkI\� <br />�� <br />CROSS STREET / [ <br />APN <br />PARCEL SIZE LAND USE APPLICATION #�j <br />OWNER NAME <br />,_jr <br />0-ndZ V" a <br />✓`tC $ <br />PHONE q Z J <br />OWNER ADDRESS LQ <br />/ Lfl Z <br />U1` <br />CA I <br />/ (:ITY/STATE/ZIP � <br />4/d <br />CONTRACTOR Ma <br />``�� <br />SC / S Uy`L1(ty 4 <br />l F <br />9 ?-PP ' <br />PHONE -4— 'Z-�'l✓/ <br />CONTRACTOR ADDRESS I L / <br />I� /� Qwi PdCITY/STATE/ZIP <br />/ � odks o , z< <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE KC -57 ❑ C-61 ❑ D-09 ❑ Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER Z Z EXPIRATION DATES 30-' <br />DOMESTIC WELL SAMPLING:'AGeneral Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Gontact 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 <br />❑Geotechnical <br />❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br /># of borings <br />LJ rvew rump LJ rump mepiacemeni L i rump mepair U maise vven uas!ng <br />WELL CONSTRUCTION <br />Drilling Method5KMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth. ft Excavation � in diameter E] Open Bottom Gravel Pack/Gravel Size* in diameter <br />E] Conductor Casing in diameter / Conductor Casing Depth / ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched .-,-' b tf-)— ❑Steel P<P-1astic E] Stainless Steel ❑Other <br />Grout Seal Depth f Op ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) ❑Other <br />Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller >kump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ❑Submersible❑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 />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED y c� ! L TITLE �J V`L I I Q V DATE /1— 31 7 <br />T <br />EP RTMENT U E ONLY <br />..n r..cd cep..... y BIC <br />Grout Inspection By J.f E'�%`~ Date <br />Pump Inspection By Date <br />Soil Boring Inspection By <br />COMMENTS %el/-nLYrt, <br />Date <br />Area "l Empioyee ID# it-x-"f'rL) <br />❑ SPE IAL Well Permit <br />❑ WAIVER Received <br />/ <br />Constructed Well Depth eX9 5 ft <br />AC- �/-/'� A'-" 4�- yj' rC <br />EHD43-06 8101/16 WELL/PUMP PERMIT <br />