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' WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE IT ALL 209 953-7697 FOR INSPECTIONS RES 1 YE FROM AT ISSUED <br /> •fit JOB ADDRESS �A N <br /> vl CITY/ZIP <br /> CROSS STREET Pp APlah �/ PARCEL SIZE �1 AN,D�,�1ISEt: ON#� p <br /> OWNER NAME c2-0 cirC ` IAYI/IT 51 n SPHONE '"UV10C/ <br /> OWNER ADDRESS-- i r to i b t o Kit -`'• t CITY/STAT I / ' <br /> CONTRACTOR • J'✓/ / P(JI 114 [�P/}(1�ONCE `r�' <br /> ry CITY/STATEIZIP -`+✓ �] V( V <br /> CONTRACTOR ADDRESS <br /> SUBCONTRACTOR PHONE <br /> HN r'r <br /> SUBCONTRACTOR ADDRESS <br /> � ITY/STATE/ZIP ' ^ <br /> 1-IJCjJ1 LICENSE C-57 �/ C-61 D-09 Other NUMBER Qa&—" XPIRATION DATE 121 <br /> v , <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dlbromochloropropane(4392) Arsenic(4393) <br /> ^ ' INTENDED USE Domestic/Private -Irrigation/Agricultural Industrial - Water Quality Monitoring Soil Sampling/Characterization 9' <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 /> Monitoring Well(s) #of wells Soil Boring #of bonngs s) Geotechnical #of borings <br /> Out-Of-Service- WWII Out-Of-Service Well Renewal .'Cross-Connection Repair <br /> v New Pum /Pum Replacement Pump Repair Raise Well Casing <br /> 1 WELL CONSTRUCTION <br /> Drilling Method - Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> ti tv Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad _Steel Plastic Stainless Steel _Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other S <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> (� Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> S PUMP Submersible Turbine Other HP 11 Pump Set W U ft Standing Water Level ft r--1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> L) 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 /> WORKE NSATION LAWS <br /> 11 MIVIPnM 24 HOUR CE NOTICE REQUIRED FOI,INSPECTIONS-PLEASE CALL(209)9 -7 97 ID <br /> SIGNED TITS )1-/'L L �� 1 r/ DATE <br /> IL <br /> C> <br /> S <br /> -� AA I- <br /> V <br /> S <br /> E iE O L <br /> Application Accepted By ate Area Employee ID#I*IW <br /> Grout Inspection By Date SPECIAL We I Permit <br /> Pump Inspection By , Date It WAIVER Received <br /> Soil Boring Inspection By Date ` ` ` Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received ---Me—ck#,T> Amount Permit/ <br /> Codes Info B emitted Date Service Request# Invoice# Well ID# <br /> -65D 9 <br /> I <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />