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zn(w Scan 51s1�, `✓ 6.11117 <br /> LLP � 'W <br /> WE / MP PERMIT U <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95206 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln�j <br /> JOB ADDRESS CITY/ZIP m <br /> / D <br /> CROSS STREET APN 1:7l PARCEL SIZE q b LAND USE <br /> y/A�P�PPLLIICATIIOONN /j 0 <br /> cp <br /> OWNER NAME 2 PHONE �iytyJ.�.((�—(/�`7G�"�O(/Dy� r? <br /> OWNER ADDRESS .J CITY/STATE/ZIPLbi ///_/'�/ /.r [ 9 <br /> CONTRACTOR PHONE�102_(/�J �� <br /> CONTRACTOR ADDRESS CITY/STATE/ZIPS, <br /> SUBCONTRACTOR PHONE Al <br /> SUBCONTRACT ADDRESS CI Y/STATE/ZIP <br /> LICENSE C-57 El C-61 F]D-09 El Other NUMBER EXPIRATION DATE '✓ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private rigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name uontact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> El Monitoring Well(s) #of wells ❑Soil Boring #of borings s) ❑Geotechnical #of borings <br /> F1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> E]NewPump VPumpReplacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method E]Mud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter E]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 E]Stainless Steel [-]Other <br /> Grout Seal 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 Installed By ❑Driller E]Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible WTurbine k2ther Qj L14U,HP Pump Set ft Standing Water Level ft <br /> 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 /> WORKER OMPENSATION LAWS. <br /> I <br /> I <br /> 124 HOtW ADVMOTICE REQUIRED FP TIONS - PLEASE CALL (209) 953-7 97 <br /> SIGNED TITL DATE <br /> Ab <br /> VA <br /> IAI <br /> 41 <br /> i <br /> VZO <br /> zoo, <br /> aU <br /> OjjN <br /> r E TAl TY <br /> MENT <br /> DEPARTMENT US.E N L Y <br /> Application Accepted By Date 1 Area Employee ID# � <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 7 2-e j ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SCReceived Ehec_W Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> L i s 3 /� x+11 sn i �t 38 5 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />