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WELL/PUMP PERMIT I? / d <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205- (209)468-3420 <br /> NON-REFUNDABLE PERMIT tyf�/� CALL 2209 953-7697 FOR INSPECTIONS C EXPIRES 1 YEAR FROM DATES ISSUED <br /> Ln <br /> JOB ADDRESS ��)�Q 1�rr;A6..1 kat,.N. nA'� CITY/ZIP S V k—A I��O,J m <br /> CROSS STREET C`J, ,.Py /''W►'tw'r^ �/ /rrn70.,,..�,�IT/ ��t�9QV�P�A�R�CgE�L SIZE LAND USE APPLICATION# v <br /> OWNER NAME '146k�^rJ..�'• ](CA I I�V'+ '� BMM'Ilj A WO-m4 PHONE�SBg-3a/��y--�a�aa N <br /> OWNER ADDRESS 1�1A.JI 1cV��`�`y'/��jjLAA �6OO CITY/STATE/ZIPsac li-am cola 95g,14 <br /> CONTRACTOR 4L�Yjj>`^C/tA4e_ C,t.y.��]\ PHONE -1Ll'-ab(0-1101 <br /> CONTRACTOR ADDRESS ao�a: 7 rC�SD�C� -P �/tC^6CITY/STATE/ZIP�C►lo WrAUV�� {aJt01 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / <br /> LICENSE XC-57 C-61 D-09 .I Other NUMBER Lha5 E%PIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)1 Arsenic(4393) <br /> INTENDED USE Domestic/Private -j Irrigation/Agricultural Industrial Water Quality Monitoring >t($oil 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 7 Replacement Well ❑Well Alteration/Modification -.Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical 4 #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal u Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary Air Rotary Auger i- Cable Tool ri 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth aS ft Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> )(Bentonite(20%solids) a Other <br /> Grout Placement Method Pumped n Free Fall Other i 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 it <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN CQUNTY 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 /> MINIMUM HO A E NOTICE REQUIRED FOR INSPECTIONS-,PLEASE CALL(209)953 7697 <br /> t r <br /> SIGNED TITL ,A� DATE /U <br /> YNIEIV71 <br /> EIVEp <br /> 1 1 2018 <br /> 0LQ I-E <br /> 1 MENZANTY <br /> PARTINENT <br /> AR M E N T <br /> Application Accepted By`� e [�/Lf!// [�-Rate L� Area�_�7(_� Employee ID# i// 7 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date �^/ tf _ WAIVER Received <br /> Soil Boring Inspection ByjW�RDate I✓ 1 Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received heck Amount ate Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Request# <br />