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WELL/PUMP PERMIT <br /> SANRJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT 0AALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ftcL [—V ! 1 i <br /> CITY/ZIP sd D m <br /> rn <br /> D <br /> CROSS STREET Ll <br /> APN 0 L f PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME S� 1/[� �, PHONE ` m <br /> OWNER ADDRESS �] \Y��1t J CITY/STATE/ZIP �,+ �7 <br /> CONTRACTOR 4A JC� ✓ +� C'1�� PHONEf� T [9 4-� <br /> CONTRACTOR ADDRESS 6CJ �( CITY/STATE/ZIP4A <br /> SUBCONTRACTOR �'1 /, �� /1. �5 (/il1�fy PHONE �~ <br /> - �1'Lo <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE le—C-57 [j C-61 F-1 D-09 ❑Other NUMBER—)>7'7 3_',W EXPIRATION DATE - <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)[-]Arsenic(4393) <br /> INTENDED USE <pomestic/Private ❑Irrigation/Agricultural ❑Industrial El Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Gontact Name or Phone Number <br /> TYPE OF WORK A<NewWell E]Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of borings #of borings <br /> ❑Geotechnical <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method.54Nud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point E] Other <br /> Proposed Well Deptl;�r �. ' Excavation /'4- in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing_ in diameter r' Conductor Casing Depth ft <br /> Well Casing Diameter�_ in Thickness/Gauge/ASTM Sched -7-00 _ ❑Steel XfPlastic El Stainless Steel ❑Other <br /> J � <br /> Grout Seal Depth / ft E]Neat Cement(94/b bag/5-10 gal water) �3and Cement !) s sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Metho Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ubmersible❑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 /> MI I M 4 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9i53-7697 <br /> SIGNED TITLE O LLJ�C - DATE ! 17 <br /> .411P IFtrip <br /> A <br /> N <br /> T <br /> DFPAC? TMEN' i i/ jE ONLY <br /> Application Accepted By r Date I Area 01 Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring1 s ection By Date Constructed Well ft <br /> COMMENTS <br /> PE Sc Received qq hec Amount Permit/Codes Info B Cash Remitted Date ervice Request# Invoice# Well ID# <br /> 36 l4W YOU3-11()/ t� <br /> 145 <br /> u oS� 7IC�5 <br /> 617 JiA S <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />