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WELL/PUMP PERMIT I(-, <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT L;ALL (LUU) VOJ-/b9/ FOR INSPECTIONS EXPIKE5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS /ACL`, -LIFu/iLG(+�flz �l%G"�% / CITY/ZIP �V <br />CROSSSTREET ''{/ J�%[Z}/ APN }/ ' 12G 12/ PARCEL SIZE '+ �/� LAND USE APPLICATION # <br />OWNERN ME {�} 91 1-nAlr.fe lift 4 PHONE Jet Z kf /yo, <br />OWNER ADDRESS�� �1�L L L�fV YF� I i G't/J�l (� V I/�+/ [iYly�� CITY/STATE/ZIP <br />CONTRACTOR��C^I qlvLI 'LI,Srj�1��%lC PHONE1 <br />CONTRACTOR ADDRESS "I' <br />/ 0�) ..�n`kit F 1 d tyety CITY/STATE/ZIP C4 I <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE W-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP_ <br />NUMBER 2c <br />PHONE <br />EXPIRATION DATE S 3 <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring NSoil Sam piing/Characterization <br />❑ Public Water System <br />If different from Owner: VV a er -ysTe-m-N a m e Contact Name or Phone Number <br />TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification El Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings WGeotechnical # of borings <br />F1 Out -Of -Service Well E] Out -Of -Service Well Renewal []Cross -Connection Repair <br />Lj New t-ump Li Hump Ke lacement LJ F'Um Ke air LJ Kaise Well Uassn <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary F1 Air Rotary Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth / - ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched [:]Steel❑Plastic E] Stainless Steel ❑Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20%solids) NOther iI (W ffigt - L"V"' sS J"V -&.0, <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: 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 />MINI U 24 HOURV( E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE <br />DATE !Ib S <br />NF-ALTy pE AR AL <br />eNr <br />Application Accepted By <br />Grout Inspection By <br />LENT USE ONLY <br />Date-a47/l, <br />Employee ID#� <br />❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Q77 Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ Amount Date PermiU Invoice # Well ID# <br />Codes Info By Cash Remitted Service Request # <br />EHD 43-06 8/01/16 <br />WELL /PUMP PERMIT <br />T <br />m <br />m <br />D <br />v <br />0 <br />m <br />m <br />EnN <br />