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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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS l j ) ( ?,, N <br /> 2-SIS(� E I eyA(,+ti A u(2 CITY/ZIP <je(.' ie n ( S-32, m <br /> CROSS STREET /. l� D <br /> f .7 APN Z,� "J I/U "��_PARCEL SIZE L'.I AND USE APPLICATION# <br /> cn <br /> OWNER NAME V��/, LJJ o S Ll C PHONE GI q�/l!S /85UQ <br /> OWNER ADDRESS d1 (oz ` �� � CITY/STATE/ZIP ESC.;1 1G n 1 ! G ((� +�0 <br /> CONTRACTOR mn s I ll b f- ( 1 t t r1_ 1 K('. ��/PHONE - l 1:22} <br /> CONTRACTOR ADDRESS 19 A�1��� ' A CITY/STATE/ZIP )y 1¢ C', <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER - EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE 'Momestic/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 ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells [_]Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well L]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method1,6fMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth 240 ft Excavation 17" ,, in diameter ❑Open Bottom )'Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameterh in Thickness/Gauge/ASTM Schede ❑Steel Plastic ❑Stainless Steel E]Other <br /> Grout Seal Depths 7,t)V ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Methoq%Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller E]Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible❑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 /> MINIM <br /> M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> 1 <br /> SIGNED ��a� TI LE ti �� DATE Z�— <br /> sJ <br /> ca <br /> 9 d� <br /> N 1 tar Q <br /> f t <br /> D PARTMENT SF, ONLY <br /> c <br /> Application Accepted Lace Area � � Employee ID# <br /> k:�" <br /> Grout Inspection By r Date SPECIAL Well Permit ` <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constru ted Well Depth ft <br /> COMMENTS i O/�5iXV t-45 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Seryice Request# <br /> L o �LI <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />