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tqft Ia5os� <br /> WELL/PUMP PERMIT <br /> SAN JONQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUN RMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDR $or►�,1yt G�rr�t CITY/ZIP 5'TOf rCt0'j ��� m <br /> CRO �J 1 V.+� <br /> SS STREET 0'yy\& (yl APN VAl7C_1S 00gOhpO60%0 PARCEL SIZE A11 'ISLAND USE APPLICATION# A <br /> OWNER NAME pB,rce2e QQla��1h1 �Y1Yla �S 1`�� �C- C PHONE 2(- ` r1y N <br /> OWNER ADDRESS 10 \� l D`Cy Ln CITY/STATE/ZIP ✓����/� G� Sad <br /> CONTRACTOR IUr'\COyn W r.Sa I r Ai rs PHONE M-30- Slo► <br /> CONTRACTOR ADDRESS `O 1. US�r�c�, WA CITY/STATE/ZIP L'0A' f <br /> ' vft 05'�Ao <br /> SUBCONTRACTOR PHONE N,f'J <br /> M-SUBCONTRACTOR ADDRESS �aY - CI, ( <br /> IITY/SSTAATE/ZIP 11/4 <br /> LICENSE 1)(C-57 ❑I C-61 I_I D-09 1_1 Other NUMBER G�g ` EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: I 1 General Mineral/Coliform Bacteria (4391)11 Dibromochloropropane(4392)I:I Arsenic(4393) <br /> INTENDED USE CI Domestic/Private 1_I Irrigation/Agricultural 1-1 Industrial I Water Quality Monitoring )Q Soil Sampling/Characterization <br /> 1-1 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well I 1 Replacement Well I I Well Alteration/Modification i I Other <br /> ❑ Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings Geotechnical #of borings <br /> ❑ Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump I Pump Replacement 1-I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 11 Mud Rotary I Air Rotary AAuger 11 Cable Tool I I Push Point 1 Other <br /> Proposed Well Depth to ft Excavation b in diameter I I Open Bottom 1_I Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I Steel ❑ Plastic I! Stainless Steel Li Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag15-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method I 1 Pumped JkFree Fall 1_I Other I1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller ❑ Pump Contractor CI Other <br /> o Concrete Pedestal I1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Il Submersible I Turbine IJ 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 /> MINIMUM HOW ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE Sen'jr ,17PPt� DATE <br /> (w <br /> J/u <br /> F�T <br /> �0 019 <br /> C <br /> \ EPARTMENT USE NLY <br /> Application Accepted By Date'7 M Areahl/Employee ID# <br /> Grout Inspection B Date I I SPECIAL Well Permit <br /> Pump Inspection By Date 1 I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re u st# <br /> �zg <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />