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WELL/PUMP PERMIT <br /> $/,N JOAQU�COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALF 209 953-7697 FOR INSPECTIONS E PIRES 1 YEAR <br /> /FROM <br /> DATE ISSUED <br /> JOB ADDRESS _ CITY/ZIP "% J�(/(/ m <br /> y� m <br /> ^E �r / n <br /> CROSS STREET[ � �APN AND USE APPLICATION#O�` / PARCEL SIZE S <br /> OWNER NAME PHONE 9l r�_� 3—3, �' ryii <br /> OWNER ADDRESS _� n` y CITY/STATE/ZIP v <br /> CONTRACTOR X&Q ��S'S / JJG/[/ �/L(, PHONE <br /> CONTRACTOR ADDRESS P CA/ '-79 CITY/STATE/ZIPC/ (0641.(Aj — <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIITYISSTATE/ZIP <br /> LICENSE C-57 [1C-61 F-1D-09El3 lYIOther NUMBER r J K EXPIRATION DATE 1� <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 Contact Name or Phone Number <br /> TYPE OF WORK , New Well Replacement Well ❑Well Alteration/Modification [I Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> []Geotechnical <br /> L]Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Methodb<Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth,:;20 ft Excavation 2- in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Irl in Thickness/Gauge/ASTM Sched—L—'ZZ? ❑Steel Mastic E]Stainless Steel ❑Other <br /> Grout Seal Depthft El Neat Cement(94/b bag/5-10 gal water) Sand Cement o, sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement MethodetgPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By PCpriller E]Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HPC 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 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 /> MINIrM�21'-&— <br /> R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED ) TITLE O jxl&�— DATE 7 [._ <br /> fit <br /> 1 � <br /> Uir <br /> Z <br /> 3 S <br /> A07T <br /> '7' ri <br /> r <br /> DE ARTMENT USE ONLY '/..� <br /> Application Accepted B f Date Area Employee ID#J�c-�C�l�� <br /> daq <br /> Grout Inspection By Date E]Date <br /> Well Permit <br /> Pump Inspection By u Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constrticted Well Depth ft <br /> CO MENTSWA yj 1A) <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Co Info I By Cash tRemitted Service Request# <br /> V 0 <br /> 7A LVEOU372 <br /> EHD 4.i-06 6/01/16 WELL/PUMP PERMIT <br />