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WELL/PUMP PERMIT <br /> SAN JOApUIN 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 CITY/ZIP q m <br /> ' / v <br /> CROSS STREET V <br /> _ APN t'� U G a' PARCEL SIZE I �. LAND USE APPLICATION# J p <br /> M U h G PHONE <br /> OWNER NAME ff�^�'�' `/J1,!/� //�� ( /� <br /> ^ CITY/STATE/ZIP_U V r�`, I (,,,4 "1�z�t P, <br /> 'OWNER ADDRESS ,�,/�/'' /�( �l � , <br /> CONTRACTOR � I,C l\ � � Cid A PHONE Y. Z-22-1 <br /> CONTRACTOR ADDRESS_ _Y V � l co )*A• CITY/STATE/ZIP - / C`'— <br /> jv <br /> SUBCONTRACTOR V PHONE 12 <br /> SUBCONTRACTOR ADDRESS A <br /> bp,4j W CITY/STATE/ZIP <br /> LICENSE C-57 IrC-61 Fl D-09 Ll Other NUMBER u EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: i 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 <br /> TYPE OF WORK ❑ New Well rip Replacement Well U Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells CI Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump # Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool H Push Point ❑ Other <br /> Proposed Well Depth5P0 ft Excavation V2 i— in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter a in Thickness/Gauge/ASTM Sched Ct0S 94-70 ❑ Steel XPlastic ❑ Stainles teel ❑ Other <br /> Grout Seal Depth 5­0 ft F7 Neat Cement(94 lb bag/5-10 gal water) Asand Cement �� sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method >Omped I-1 Free Fall ❑ Other 1-1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller )6 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width'ft Length_�ft Thick % in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ SubmersibleA Turbine 11 Other HP 10 0 Pump Set_'1100 ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORCANCE 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 /> MINI 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECyS -PLEASE CALL (209) 953-769/70 <br /> SIGNED ` �� TITLE DATE67, <br /> I IN IM <br /> WA <br /> O , <br /> A <br /> EI RTMENT U E f: L`i II �,' <br /> Application Accepted By ' Date tai Area y Employee ID# W <br /> Grout Inspection By Date ` ❑ SPECIAL Well Permit <br /> Pump Inspection By1Vr11RT �]n Date ����.������ ❑ WAIVER Received <br /> Soil Boring Insp ction By Date Constructed Well Depth ya ft <br /> COMMENTS © �D,�,i e.e C �T_ 1 (� CJ •. 7-- <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info BYAI Remitted Service Request# <br /> 23 1 Goo R 18 <br /> 43Yu c�So 3 5 23 I VU <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />