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WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 /> Ln <br /> JOB ADDRESS 2.t) j^,raAQV% RZIA __ CITY/ZIP F5!C6( /OH C4 9 m <br /> �1 D <br /> CROSS STREET `rW 1'tf�''�__'p4t APN 216T OI&0-380 PARCEL SIZE 3 aid LAND USE AP�PL/IICCATION# J A <br /> OWNER NAME M1�u1l �61Vj PHONE 8q7- 67-7 <br /> OWNER ADDRESS Aq^3be,33 1� • JN01� LY%. CITY/STATE/ZIP 45WO)I ( r1 `7 i3 21/ <br /> CONTRACTOR I v 1 QSe 1 i , <br /> S fN]h �hC PHONE <br /> C ;? 1��C 2 C� <br /> CONTRACTOR ADDRESS IN-1 A bt l-5 1� _ CITY/STATE/ZIP �e0 /J D i (_tel � + ✓✓ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE _57 I C-61 i I D-09 Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I 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 I Well Alteration/Modification ii Other <br /> Monitoring Well(s) #of wells !I Soil Boring(s) #of borings Geotechnical #of borings <br /> r; Out-Of-Service Well I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> i New Pump Pump Replacement Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger I i Cable Tool l I Push Point i! Other <br /> Proposed Well Depth ?>(50 Excavation �_ in diameter [I Open Bottom {Gravel Pack/Gravel Siz in diameter <br /> Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel XPlastic I I Stainless Steel I I Other <br /> Grout Seal Depth1 ()0ft ❑ Neat Cement(94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> >(Bentonite(20%solids) ❑ Other <br /> Grout Placement Method umped r1 Free Fall Other I! Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller I I Pump Contractor I I Other <br /> ❑ Concrete Pedestal I]Dimensions:Width ft Length ft Thick in I! Christy Box Stove Pipe <br /> PUMP n Submersiblel l Turbine I I 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 /> M M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697Q <br /> SIGNED T �1O DATE <br /> Ad <br /> O <br /> a <br /> `y <br /> O N <br /> SN MN <br /> T <br /> E P TMENT USE ONLY <br /> Application Accepted By Date� Area Employee ID# <br /> Grout Inspection By bate h�wf� <br /> ILILi1,, ❑ SPECIAL Well Permit <br /> Pump Inspection By \ Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date_ Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash mitted Service Request# <br /> 26 <br /> FHD 43-06 8/01/16 WELL/PUMP PFRMIT <br />