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RECEIVED <br /> r MAY 2 9 2018 <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA VMQW' EN-IAL H E A L"1'H <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DAT RTN1 E NT <br /> JOB ADDRESS FT. CITY/ZIP S <br /> k c✓ <br /> lk 1 1 O <br /> CROSS STREET W AIN V' PMCEL SIZE�WiD USE A�PPP{LICATIOONC#�j Gc� m <br /> OWNER NAME •\� ( Q� PHONE <br /> �(lL 't) "tom"lt�Z <br /> OWNER ADDRESS �O\� rv`. CFTY/STATE21P S�OCVA - lGr\V1'-\ 1SQ�L�S (V <br /> CONTRACTOR \ l- PP{HOONE'f �L2t���)) C� lc�� N <br /> CONTRACTOR ADDRESS v w CITY/STATEZP 5k-C '�1�T 1 "\=7 ZOC' <br /> SUBCONTRACTOR N,^ PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATE/ZIP /0 <br /> LICENSE -57 '�d1 D-09 Other NUMBER EXPIRATION DATE nj <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED USE -,c.Domesticiprivate Irrigation/Agricuttural Industrial Water Quality Monitoring Soil Sampling/Cheracterization <br /> Public Water System <br /> If different from Owner water systern Narne ame or u <br /> TYPE OF WORK New Well Replacement Well Well Alterabon/ModiFication Other <br /> Monitoring Well(s) #of wells Soil Boring(s) it of borings Geotechnical #of bonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump /sPump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tod Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pacit/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal watef) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placemerrt Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length It Thick in Christy Box Stove Pipe <br /> Pure txnerside Turbine Other HP Pump Set (D ft Standing Water Level <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN N <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 /> MINIMUM 2 H JJ NOTICE REQUIRED FOR I CTIONS/-PLEASE CALL(209)953- 7 Aq •- <br /> SIGNED - TITLE � �// DATE <br /> VZ 6 ,2018 <br /> V�N C <br /> OUIV <br /> N7.4t 7-y <br /> NeNr <br /> Itt <br /> , , i (EPA TMENT U E O Y QA <br /> Application Accepted ByDate Area "l 1 Employee ID# <br /> Grout Inspection By Date !_ SPECIAL Well Permit <br /> Pump Inspection By Date it) I. WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received (-c"-sw Amount I Date pew Invoice i Well ID# <br /> C s Info B Remitted i <br />