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WELL/PUMP PERMIT I" <br />el J 't °10 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />CALL <br />ADDRESS L ,% '� J s v/ 1/ i J 1/11 t: l.4 I tt I- 1.1 <br />ss STREET `I /�/� /. /� AyP�N Z53- 2?'o —V—PARCEL <br />IER NA7tM7- U IG 1 `Vt 1 I 1 K A� ( G <br />1 <br />YEAR FROM DATE <br />USE APPLICATION # <br />OWNER ADDRESS <br />1 I /7 t- L4`1 I <br />Iy U <br />rryblTV/STATE�P �1 <br />CONTRACTOR ��/[ <br />�V { <br />•, �' (/ j <br />" %" / PH NE <br />Conductor Casing in diameter / Conductor Casing Depth it <br />/� <br />tt!4 <br />VaCITY/STATE/ZIP <br />Diameter _ in Thickness/Gauge/ASTM Schad Steel J Plastic Stainless Steel Other <br />CONTRACTOR ADDRESS `� <br />`� • u <br />Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br />SUBCONTRACTOR WW <br />i <br />PHO,ivla <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 <br />ISIN/STAT1/E <br />C 61 D-09 <br />Other �/� <br />IIP <br />NUMBER /]/(w/ " (✓^ EXPIRATION DATE <br />DOMESTIC WELL_S�%IPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DomeStir/Private Irrigation/Agricultural Industrial Water Quality Monitoring 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 Bohng(s) # of borings Geotechnical # of borings <br />Out -Of -Service Wyll Out -Of -Service Well Renewal - Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing <br />y <br />m <br />D <br />z <br />Drilling Method <br />Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well <br />Depth ft Excavation in diameter Open Bottom - Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Schad Steel J Plastic Stainless Steel Other <br />Grout Seal <br />Depth ft Neat 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 <br />Installed By Driller Pump Contractor Other <br />oncrete Pedestal Dimensions: Width ft Lent ft Thick in Christy Box - Stove Pi e <br />PUMP <br />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 />t� <br />CURRENT ANGSACTIVE <br />WITH THE CALIFORNIA CONWCTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />^� 1 <br />WORK <br />NSATION A <br />^ <br />�#5 <br />24 CE IR D FO'FkINSSPECTIIOeN(S - PLEA CALL (209) 9� 7 <br />QW <br />SIGNED <br />TITLE �`' '�I tea. r • r• IA DATE 1 <br />RE <br />MAY <br />ENVIRok4i <br />DEPA <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Baring Inspection By <br />COMMENTS <br />Date <br />✓& . IVrl <br />�1 <br />vR2018 <br />SPECIAL Well Permit C <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD 43-06 6/01/16 <br />WELL /PUMP PERMIT <br />