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I 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 /> JOB ADDRESS 55 73 W, Y4 1 6f tC�1 Q Iz j CITY/ZIP L—Q d /64 m <br /> m <br /> i -J D <br /> CROSS STREET T�I'Z�L. Q �A/P�NN01 i11 /05 Z L PARCEL SIZE "46,12 LAND USE APPLICATION# <br /> OWNER NAME �L UF�ti% !� IAA IJ��'J1W/ W PHONE <br /> OWNER ADDRESS �( 09 h CITY/STATE/ZIP:i�zz:L64 �� <br /> CONTRACTOR /fic1 � � cC/Soh HONE ��--j <br /> j 2 9y - �013 <br /> CONTRACTOR ADDRESS 902- n 54yinif CITY/STATE/ZIP boj'ZC14/ '152/o <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY//,S�TAAyT�E/ZIP <br /> LICENSE C-57 IJ C-61 1-1D-09 I 1 Other NUMBER -1 w EXPIRATION DATE 5/31//j <br /> DOMESTIC WELL SAMPLING: 1 General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private 17 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 /> ❑ Monitoring Well(s) #of wells (Soil Boring(s) 5 #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump Cl Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth UC—I's ft Excavation A in diameter ❑ Open Bottom I I Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft XNeat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other org <br /> Grout Placement Method ❑ Pumped Free Fall i Other—ffz '� ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor P Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible[] Turbine ❑ 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 NIMU/ 48�JH UR ADVANCE NOTICE REQUIRED FOR/INSPECTIONS -PLEASE CALL (209) 953-�7769j7 <br /> L <br /> SIGNED 1 '��i' TITLE L7�i/�iJa/5 DATE <br /> H QL4 I <br /> El MOMNAL <br /> T D <br /> EP RTMENT USE NLY qq <br /> Application Accepted By Date Area Employee ID# kA AL <br /> Grout Inspection By Date CI SPECIAL Well Pelrmit <br /> Pump Inspection By Date 1_l WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes In Cash a itted Date Service e t# Invoice# Well ID# <br /> 'Alo At <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />