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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 PERMIT CALL 209 953-7697 FOR INSPECTIONS �E1�XPPEIR S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I �Sk <br /> CITY/Z1P (` n X 5320 <br /> CROSSSTREET Q/USVA R APN�n PARCEL SIZ&.I—LAND USE APPLICATION# D <br /> I Ulu A <br /> OWNER NAME PHONE I(2 1 an��vr�7 1 InX�lY <br /> OWNER ADDRESS OLAW`/1 '^n CITY/STATE/LP EW`�Vr'Y�t Q1✓o�Ll/o <br /> CONTRACTOR ��W\11/"�i'liyyfef I ►J,IL/:�� /'/� PHOOINE fI-V�/�� <br /> CONTRACTOR ADDRESS ��CTy (-L I I t/f /1 V Y_ CITY/STATE/LP S O {DY 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR <br /> ADDRESS CITYISTATE/LP <br /> LICENSE �/C-57 C-01 D-09 Other NUMBER 93 449S E%PIRATION DATE <br /> DOMESTIC WELL SAMPLING:. 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 w <br /> TYPE OF WORK New Well ' Replacement Well I-I.Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of bonngs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> Vi eew Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION Z8 a01 <br /> Drilling Method Mud Rotary i Air Rotary i Auger Cable Tool Push Point Other ` <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size <br /> Conductor Casing in diameter / Conductor Casing Depth ft TN pMFNrq(�. <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic -Stainless Steel I Other F <br /> Grout Seal Depth It I Neat Cement(94 Ib bag/S10 gal water) Sand Cement sack mix17 gal water M N� <br /> Bentonite(20%solids) i 1 Other <br /> Grout Placement Method i Pumped Free Fall i Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Length ft Thick in Christy Box I Stove Pipe <br /> PUMP ubmersible Turbine Other HP Pump Setft 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 /> MINIMUM 24 HOIRADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)963-7697 <br /> SIGNED TITLE �` �. DATE <br /> ,A TMENT U E NL <br /> Application Accepted By Data Area Employee ID#i1!!jj!jW <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By �� Date 0� 1 � WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permltl Invoice# Well ID# <br /> Co s Info C sh emitted Se ice Re uest# <br /> Q t' <br /> EHD 4306 8/01/16 // �/J 2 J ,�/ WELL/PUMP PERMIT <br />