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WELL/PUMP PERMIT <br /> SAN J(1AQWN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �"/ i v L /v� CITY/ZIP S�/�C�I� s��) m <br /> CROSS STREET / aw 4�6 APN PARCEL SIZE LAND USE APPLICATION <br /> # o <br /> OWN�NAM � Li t e I J � /// PHONE 6 v 7-ix <br /> OWNER ADDRESS <'s�`�r►va CITY/STATE/ZIP <br /> / <br /> CONTRACTOR A ( A&)rf' ? ^ PHONE <br /> n <br /> CONTRACTOR ADDRESSpp���� CITY/STATE/ZIP '/�rL <br /> SUBCONTRACTOR (fir PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> C-57 ❑C-61 ❑D-09 ❑ V-2 <br /> Other NUMBER ,i9 EXPIRATION DATE 6110 <br /> DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name uontact Name or Phone Num er <br /> TYPE OF WORK, New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring( ) ❑Geotechnical S #of borings #of borings <br /> Out-Of-Service Well E]Out-Cf-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ' ud Rotary F]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth—i5�t) ft Excavation IV in diameter [-]Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ConduF�f Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter a in Thickness/Gauge/ASTM SchedZ?0 El Steel x1plastic E]Stainless Steel ❑Other <br /> Grout Seal Depth_ !!�2- Lft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement Zo�J sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method,<Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Rfriller ❑Pump Contractor ❑ Other 0 462 <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑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 /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HO DVANC NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9553-7697 y.� <br /> SIGNED TITLE el DATE 61L <br /> DJS LIS <br /> It <br /> I lilt, 1 ') 4171J <br /> INC U <br /> VM ENTAL <br /> J <br /> D� PARTMENTUS ONLY <br /> Application Accepted Date YU Z Area Employee ID#W f" <br /> Grout Inspection By Date ❑ SPECIAL Well Permit r <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dae onstructed Well Depth ft <br /> COMMENTS Q — <br /> PE Sc Received Check#/ Amount PermiU <br /> Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> 3- a 0Z' z III s b'l7 z <br /> Z S U-11 2.5 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />