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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 76'117 f1 fl��-T,c/2 2-L'- c9 CITY/ZIP Ae47^7,00 67522-0 m <br /> CROSS STREET PNS 1 1 y-,r ))a, APN PARCEL SIZE4j LAND USE APPLICATION# o <br /> z <br /> OWNER NAME 177 PHONE Z>7_3 35 —zU�n y <br /> OWNERADDRESS r 1 �. J��n j�Z_ CITY/STATE/ZIP f}•L/tz!�QC7 5-7-20--7 <br /> CONTRACTOR ?-iZ.tx('YI f/I_I�,..� PHONE;'ID�—�j�'�^ /O <br /> CONTRACTOR ADDRESS�)OL 1,--rDuS:Ttr�C( 1✓ CITY/STATE/ZIP L410'1 6-4 -,j,57 L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE ,'r!6-57 LI C-61 Li D-09 LI Other NUMBER /'tl ad EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:U General Mineral/Coliform Bacteria(4391)._;Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE I Domestic/Private i I Irrigation/Agricultural I I Industrial I.1 Water Quality Monitoring XSoil Sampling/Characterization <br /> I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 11 New Well I.I Replacement Well Il Well Alteration/Modification LI Other <br /> D Monitoring Well(s) #of wells Soil Boring(s) .1�- If of borings U Geotechnical x of borings <br /> 11 Out-Of-Service Well n Out-Of-Service Well Renewal I i Cross-Connection Repair <br /> I I New Pump I I Pump Replacement U Pump Repair it Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method i1 Mud Rotary r I Air Rotary /Auger IJ Cable Tool U Push Point (I Other <br /> Proposed Well Depth 1_ft Excavation (g in diameter I I Open Bottom r I Gravel Pack/Gravel Size in diameter <br /> Il Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Li Steel I I Plastic rl Stainless Steel I I Other <br /> Grout Seal Depth15- ft /eat Cement(94 lb bag/5-10 gal water) LI Sand Cement sack mix17 gal water <br /> 1.1 Bentonite(20%solids) 11 Other <br /> Grout Placement Method ::I Pumped ZFree Fall 0 Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By rl Driller i I Pump Contractor 11 Other <br /> t.I Concrete Pedestal UDimensions:Width it Length If Thick in LI Christy Box 0 Stove Pipe <br /> PUMP it Submersible'I Turbine I I Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 R QUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7697 <br /> SIGNED <br /> SjTLE—• /tJ C./ /1 ) DATE <br /> !i iiv i 9 <br /> NTY <br /> Etti i O ME IT L <br /> H H = A ENT <br /> _ —DEPARTMENT //USE O LY <br /> Application Accepted By Date C L C Area �� Employee ID# <br /> Grout Inspection By Date 11 -SPECIAL Well Permit <br /> Pump Inspection By Date LI WAIVER Received <br /> Soil Boring Inspection By 4 L Date Q (/ Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info (B Cash Remitted Service Request# <br /> ��/ �I � 1. • _ � L' �;l JI -�+ <br /> EHD 43-06 6/01/16 <br /> WELL/PUMP PERMIT <br />