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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 <br /> (PERMIT <br /> ( CALL 209 953-7_697 FOR INSPECTIONS �`r EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS `-l? �l S4 �+ %ZU t4L,,)l CITY/ZIP }.Ste/ 7 �Z� m <br /> �'` 4400 <br /> Q D <br /> CROSS STREET APN ZVI 270 700 PARCEL SIZE ?•S LAND USE APPLICATION# o <br /> w <br /> A <br /> OWNER NAME SGV 1�Q rl�rA VL'L� PHONE�� ���g���-C�7�jf <br /> OWNER ADDRESS 2 ` LV ryoA^ r_ � CITY/STATE/ZIP AVL N 0 CIA e 7 <br /> CONTRACTOR 1' CLS cuiS DrI1lN")!% Twc PHONE <br /> � Co-CONTRACTOR ADDRESS I l 9 A l b ers Ua CITY/STATE/ZIP Md--54v, Cq533-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ( r Q <br /> LICENSE 'KC-57 i 1 C-61 I D-09 I Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:- eneral Mineral/Coliform Bacteria (4391) ! I Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring I I Soil Sampling/Characterization- <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone N <br /> TYPE OF WORK I I New Well Replacement Well Li Well Alteration/Modification 1-1 Other <br /> I 1 Monitoring Wells) #of wells ❑ #of borings #of boringsSoil Boring(s) I I Geotechnical��� �� o <br /> I,I Out-Of-Service WFum Replacement ❑ Puml Li p Repair e Well Renewal n Raise Well Casion RepagA�JO'gQUI� <br /> WELL CONSTRUCTION EALTy p ft1Elok <br /> Rotary <br /> Drilling Method XMud Rota 1 Air Rotary I I Auger ] Cable Tool [J Push Point U Other EPA,2TME <br /> Proposed Well Depth__2.56 ft Excavation 12- in diameter I Open Bottom Gravel Pack/Gravel Size Im in diameter <br /> I Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched__2eb U i i Steel xeplastic i' Stainless Steel Other <br /> Grout Seal Depth /b 0 ft ❑ Neat Cement(94 lb bag/5-10 gal wate/) I 1 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Wumped 1 Free Fall Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor n Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in I I Christy Box n Stove Pipe <br /> PUMP SubmersibleP Turbine 1 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 /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)`953-7b697 d <br /> SIGNED �— Ti I_E r DATE / �7 7 <br /> J � <br /> e <br /> rR <br /> b <br /> -V 00000 k, <br /> l <br /> \ DEPARTMENT USE ONLY (� <br /> Application Accepted By Date ( 5� ZArea r Employee ID# tA <br /> Grout Inspection By �s - \ Date �,� O SIECIAL 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 CheckAmount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted ervice Request# <br /> I AA-1 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />