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114 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT '- /n ' l CALL 209 953-7697 FOR INSPECTIONS C EXPIRES I YEAR FROMDATEISSUED <br />JOB ADDRESS x.04-1 yo �^' 6 � Lano, ` l /M� / CITY/Zip `� 4 9C I 1 ✓`� <br />CROSS STREET � tLwA 15 �/ APN 1 �p7 O VQ`� " I PARCEL SIZE ilf"i z LAND USE APPLICATION # <br />OWNER NAME P', C r 1 �/ (� A S do G I (I L I V I �_ PHONE <br />OWNER ADDRESS CITY/STATE/7JP <br />CONTRACTOR `�I ,' 1 �. /p V I I�,1 PHONE �I qqr— 1 <br />CONTRACTOR ADDRESS �0 - r E RA V f IVV CITY/STATE/ZIP s ` !✓ <br />7,06 <br />r <br />SUBCONTRACTOR % I� �� /l Cl PHONE 1� <br />G, <br />SUBCONTRACTOR ADDRESS IK I)e^4 r S F _ CITY/STTA(T'EEIDP C' .I G 9 <br />LICENSE j C-57 ElC-61 ❑ D-09 D Other NUMBER Z6 v EXPIRATION DATE O w' <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE D Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Characterization <br />D Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well D Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells D Soil Boring(s) # of borings Geotechnical # of borings <br />D Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Puma Puma ReDlacement _I Puma Reoair ❑ Raise Well Casino <br />Drilling Method ❑ MudRota ❑ Air Rotary Auger 11 Cable Tool ❑ Push Point 11 Other <br />Proposed Well Depth 96 Excavation in diameter D 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 ❑ Stainless Steel D Other <br />Grout Seal Depth ft j Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />D Bentonite (20% solids) D Other <br />Grout Placement Method Pumped D Free Fall D Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller D 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 It Standing Water Level it <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 />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />PPARRTTMENT USE ONLY <br />y Date <br />'I!Vl�l legate <br />Date <br />Date <br />- PLEASE CALL (209) 9 3-7697 <br />L��� DATE <br />m <br />N <br />� \% W <br />Area yr r�i1 EmploD#/n� <br />❑ SPECIAL Well Permit <br />F1 WAIVER Received <br />Constructed Well Depth ft <br />PE SC Received Check#/ Amount Date Permit' Invoice # Well ID# <br />Codes Info 8 Cash Remitted Service Request 9 <br />2 IS v <br />EHD 43-06 revised 4114/18 WELL /PUMP PERMIT <br />