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1 / <br /> WELL/PUMP PERMIT ✓ <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE P/ERMITf CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / <br /> JOB ADDRESS / / CITY/ZIP f/7�/1r'ff /7 �-3(C/ m <br /> CROSS STREET /� ' �= �C AP/N�/'O� Cillo "l O PARCEL SIZE 7 LAND USE APPLICATION#Q / A <br /> OWNER NAME /�/��y�l�l+sl ���+fes PHONE �� �L/ - (C�/�6 <br /> �} N <br /> OWNER ADDRESS �1y� � ��/" �� CITY/STATE/ZIP L�r��t�/��/� lt �5 J .3 f� <br /> CONTRACTOR �� // [ 1/�'�l` ` % �L / PHONE CL�� 7r� - ?-7 j <br /> Y^ 7 <br /> CONTRACTOR ADDRESS �} 1'eye- lll�lJrr� I1'/ CITY/STATE/ZIP (�� eZZ ����J7 e^ ✓����y <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE LJ -3 z�, <br /> DOMESTIC WELL SAMPLING i 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 ❑ Other <br /> #of borings p Qf'Iprrpgs <br /> ❑ Monitoring Well(s) #of wells Li Soil Boring(s) ❑ Geotechnical civ <br /> D16110 JT" <br /> Out-Of-Service Well �❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair VE <br /> ❑ New Pum t `ilPUm Repair ❑ Raise Well Casing [� <br /> WELL CONSTRUCTION ' (- 1 <br /> Drilling Method CI Mud Rotary F1 Air Rotary ❑ Auger 11 Cable Tool Ll Push Point 11 Other 2��8 <br /> Proposed Well Depth ft Excavation in diameter 11 Open Bottom [I Gravel Pack/ /N Cn diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft N `�QEPgR'�E <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched I 1 Steel ❑ Plastic ❑ Stainless Steel ❑ Other MT <br /> Grout Seal Depth ft ❑ Neat Cement(94/b 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 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor [I Other <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box [_l Stove Pipe <br /> PUMP ;9.Submersible[] Turbine CI Other HP Pump Set ZVft 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 48 cR AAD7VA�NCE REQUIRED FOR <br /> INSPECTIONS - LEASE CALL (209) 953-7697 <br /> SIGNED l� f TITLE C/�c � �/!� X`%:1/ DATE lLI <br /> 7 <br /> 77 <br /> v <br /> EP RTMENT U E O LY <br /> Application Accepted By Date I I f U Area Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By I Date J Z 711 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date Permit/ Invoice# Well ID# <br /> Cods Info m tte j Service Request# <br /> 0 517 <br /> Z <br /> EHD 43-06 8101/16 WELL/PUMP PERMIT <br />