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WELL/PUMP PERMIT P / <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL 209 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS )� 1 <br />t <br />d{�� 4Lf Gf; ;i(r c.r,� A'C".'•& CIT'/'Z'IP•.:�,•1C<c. <br />/ <br />CROSS STREET !'1'���-)i�.'1 <br />V: �J'f-. <br />J�C�`/ <br />APN .G�`i _ SSC — 1pLi ! PARCEL SIZE j�,�LAND USE APPLICATION # <br />OWNER NAME 1.-1 �.. r`=� <br />(.: %-1, C <br />, <br />PHONE <br />OWNERADDRESS /�L C%O r' <br />- ~I <br />.1 <br />iWY ��I CITY/STATEZP <br />/ / <br />Q.?01 CFF TS366 <br />CONTRACTOR W <br />TJr:lt�ry <br />-rat.— <br />L� <br />E 2,-4(O,I—,Zcc <br />CONTRACTOR ADDRESS I .3 <br />�tr+(' I/ <br />T� <br />h v.(-h'Y D r, !2 CITY/STATE/ZIP <br />/,PH <br />ll 4.l -r,/ ( A ( cf 5-6 '3 2 - <br />SUBCONTRACTOR <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CRY1/S^TATE21P <br />LICENSE -57 ❑ C-61 <br />❑ D-09 <br />ElOther NUMBER / z��� i <br />EXPIRATION DATE 0`{ - '3u -2018 <br />DOMEsnc WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (439 1) ❑ Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE ❑ DomesticJPrivate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring KSoil 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/Modificabon ❑ Other <br />❑ Monitoring Well(s) # of wells X Soil Boring(s) Z # of borings ❑ Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth IS— ft Excavation 4 4, t/ 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 Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft Meat Cement (94 Ib 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 ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimenslons: Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set It 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 />At <br />IMUM 24 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />r <br />SIGNED ✓" —� TITLE ✓ 1 1� 1 V `'^'� ! DATE - - — ` — I' °l <br />PW <br />Application Accepted By <br />Grout Inspection By <br />MENT YSE O'I <br />(�f <br />Data <br />- 3 <br />Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date G <br />COMMENTS <br />Area Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />EHD4306 6/01/16 WELL /PUMP PERMIT <br />