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ZLp" WELL/PUMP PERMIT <br /> SAN JCAQUIN 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 � CITY/ZIP 43— P m <br /> CROSS STREETI /���/J �i�- APN wL� PARCEL SIZE _LAND USE APPLICATION# S <br /> OWNER NAME <br /> ,,C ; �. ac`c .I/ fl/ 7 PHONE —;�y ,; ufni <br /> OWNER ADDRESS /yj'1� y r CITY/STATE/ZIP © 1 <br /> CONTRACTOR /fid- �i' s'S ,L[' �/� PHONE 'r3s Y- 41'7 2,r <br /> CONTRACTOR ADDRESS 6 CU7V 1778 CITY/STATE/ZIP ��� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >?�C-57 El C-61 F1 D-09 ❑Other NUMBS � � EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring El Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water 6ystem Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> El Monitoring Well(s) #of wells E]Soil Boring #of borings s) ❑Geotechnical #of borings <br /> E]Out-Cf-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> I;Lmew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,.j?Mud Rotary E]Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth j�y ft Excavation _ in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-m6— in Thickness/Gauge/ASTM SChed-1 El Steel V-Plastic E]Stainless Steel []Other <br /> Grout Seal Depth 45D ft ❑Neat Cement(94 Ib bag/5-10 gal water) •.[Sand Cement fv., j sack mix/7 gal water <br /> F-1 Bentonite(20%solids) ❑Other >0 <br /> Grout Placement Method JerPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ruler ❑Pump Contract?f� E] Other <br /> ❑Concrete a estal dimensions:Width ( ft Length ft Thic in ❑Christy Box ❑Stove Pipe <br /> PUMP y<Submersible❑Turbine ❑Other HP_a_ 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 /> MINIM M 24 HO ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED -'C W TITLE OL�/�/� DATE <br /> he <br /> kA <br /> ti <br /> � a <br /> ci Vi O"MNT ,L .. <br /> y Tri D. T <br /> U PARTMENT USE ONLY <br /> Application Accepted By '7Date 30 Area " 1 Employee ID#Z=�(7 <br /> Grout InspectiojBy <br /> Date ❑ SPECIAL Well Permit <br /> Pump InspectioJ Date ❑ WAIVER Received <br /> Soil Borin nspection By Date Constructed Well Depth <br /> COMMENTS i Is O <br /> O p P n <br /> x <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Reque t# <br /> 3 15- <br /> wo. <br /> 0 O 348 0 <br /> l 3 � I <br /> EHD 43-06 8/01/16 ( S7 I ���J �`S N 5• Q"'ei WELL/PUMP PERMIT <br />