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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDA13LE PECK/MI I <br />I.ALL LUt7 V03 -10b/ FUK I1,15PEG HUNS CAYIKtJ I TEAR FROM DATE 15SUED <br />JOB ADDRESS <br />r <br />. <br />CITY/ZIP Trru� <br />CROSS STREET <br />APN Jl -Wy - (1190- <br />a,f0PARCEL SIZE (0-� ,-"-' LAND USE APPLICATION # <br />I <br />- <br />C <br />igoo <br />OWNER NAME <br />m -o I <br />ikOb <br />T I <br />1 1y <br />PHONES30) 2ZZ- <br />OWNER ADDRESS I <br />V <br />CITY/STATE/ZIP k0figinIJ of'4 a <br />CONTRACTOR <br />- 1 o- 4 o <br />l r—VI <br />PHHO`NE!, <br />-r. �,t- 3 <br />CONTRACTOR ADDRESS <br />d�O <br />, /r11L i <br />/ _ <br />CITY/STATE/LP U�SQ Y/.Gralh.l Yl C/^t' e <br />', <br />J <br />III <br />`L'!1/1 <br />f <br />SUBCONTRACTOR V and <br />n <br />PHONE <br />SUBCONTRACTOR ADDRESS 11333jlack.h <br />li�[ �r. <br />^ <br />CITYISTATE/ZIP 011k• A <br />LICENSE n-57 <br />I C-61 i' <br />D-09 Other <br />NUMBER 12L21� ExPIRATioNDATE tLl d <br />DOMESTIC WELL SAMPLING: I i General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) I I Arsenic (4393) <br />NTENDED USE i Domestic/Private , Irrigation/Agricultural i Industrial i Water Quality Monitoring i 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 I! Replacement Well ❑ Well Alteration/Modification a Other <br />MonitoringWell(s) #of wells ' Soil Boring(s) aofbonnga >C Geotechnical _#of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />New Pump ! Pump Replacement Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary ❑ Air Rotary 'CAuger Cable Tool 1 1 Push Point Other <br />Proposed Well Depth 10-5'0 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 i I Steel I Plastic i Stainless Steel i Other <br />Grout Seal Depth 6_ft 1'./Neat Cement (94 /b bag/510 gal water) Sand Cement sack mixf7 gal water <br />Bentonite (20% solids) I Other <br />Grout Placement Method umped 1 Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length it 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 />MIt�]t(�J�UM'48 UUR_A.DVVANCE NOTICE REQUIRED FOR INSPECTIONS -/PLEASE CALL (209) 953 76 <br />SIGNED '.A_ //a'�V rl fiM?7 TITLE (_7 .416cr,C i DATE '97 `f I ! 7 <br />A,[2 MENT U O L <br />Application Accepted By�—1 ate <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection BYA Date <br />COMMENTS <br />AreaEmployee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />ft <br />EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />