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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(209053-7,697 FOY,INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> G1M1LL!� <br /> JOB ADDRESS \ CITY/ZIP J !J lJ m <br /> C c j D <br /> CROSS STREET N_ D �1L1V�APN ZS S -OZQ /�]?- PARCEL SIZIEtO.DO LAND USEAPPLICATION# Co <br /> 0 <br /> OWNER NAME �y,� GC'.i.� P.ODCr'�sor+/ V.E•W R I��OCX+C O!?J'{ _ PHONE {O la- S L Z5-76-/LJ�O( � cn <br /> OWNER ADDRESS 1� '� MON[> Ye. �T� CITY/STATE/ZIP L C r r✓�10 <br /> CONTRACTOR Q ` hO,S�1 �!� �Y�C• PHONE 5 L — 11 V J <br /> CONTRACTOR ADDRESS L� `�-" '�CY CITY/STATE/ZIP MoAC 54- , c A q 5356 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 1 C-61 I D-09 Other NUMBER x_010 1 J EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 11 Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring i l Soil Sampling/Characterization <br /> "Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKew Well [IReplacement Well LI Well Alteration/Modification LlOther <br /> LI Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I 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 X <br /> ud Rotary Air Rotary I! Auger Cable Tool u Push Point Other <br /> Proposed Well Depth L�QD ft Excavation - in diameter fI Open Bottom Gravel Pack/Gravel Size(O in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-8- in Thickness/Gauge/ASTM Sched$b� � Steel lastic Stainless Steel Other <br /> Grout Seal Depth ZO I--) ft LI Neat Cement(94 Ib bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) li Other <br /> Grout Placement Method Pumped 1-1 Free Fall I I Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Wump Contractor [I Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in I I Christy Box I I Stove Pipe <br /> PUMP Submersible❑ Turbine i I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR\INSPECTIONS - PLEASE CALL (209)/-953-7697 <br /> SIGNED CJ" TITLE V DATE 10-)-3'1 9 <br /> ITT <br /> q <br /> T M U <br /> T <br /> PA TMENT U E O LY <br /> Application Accepted By Date Area "/ Employee ID# <br /> z <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By y Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By_ Cash emitted DateService Request# Invoice# Well ID# <br /> - ''Aq 0 <br /> {$ 01� 5101262 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />