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/-j V'AA j r r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDAB E PE M T W S OV.OI /ehd EXP RES YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' ua • CITY/ZIP `�'1 m <br /> APN D <br /> ROSS STR�� r <br /> �/ �� " /PSA-R�'CflEL IZE / �.LA/ND USE APPLICATION# <br /> IV Vh�C j v "� f L.C. 5 �/L"V%— �, �l f V u�f umi <br /> WNE NAME PHONE <br /> OWNER ADDRESS l WI off) CITYISTATEI IP(AIC 4 <br /> CONTRACTOR ! ' ✓ c' w•I a3 /P/H)ONE <br /> CONTRACTOR ADD RES CITYISTATE IP ►`V � �V <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS `V 4 <br /> C <br /> IT <br /> Y/ <br /> STATE/ZIP <br /> LICENSE -57 -61 D-09 O I <br /> �i0 J � ' •yam• <br /> BILLING PARTY: OWNER n CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)- Dibromochloropropane (4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private u Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil Sampling/Characterization <br /> _ Public Water System V� <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK _ New Well U Replacement Well u Well Alteration/Modification -1 Other <br /> Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ <br /> Out-Of-Service Vyell a Out-Of-Service Well Renewal a Cross-Connection Repair (� <br /> - New Pump Pump Replacement ❑ Pump Repair E Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary U Air Rotary a Auger Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter _i Open Bottom L Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched u Steel u Plastic _ Stainless Steel a Other O <br /> Grout Seal Depth ft f1 Neat Cement(941b bag/5-10 gal water) rl Sand Cement sack mix17 gal water �+ <br /> - Bentonite(20%solids) ❑ Other <br /> Grout Placement Method - Pumped n Free Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By = Driller ❑ Pump Contractor Other <br /> oncrete Pedestal uDimensions:Width ft Le gth ft Thick in _ Christy Box U Stove Pipe C <br /> PUMPV Submersible- Turbine n 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 COU TY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. ! ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AN TIVE WITH E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C NSATION S. <br /> MI OUR ADVANCE NOTICE REQUIRED FPR{/��I)N/S)/P�E/C�TI/O�JN�S -PLEASE CALL (209)J953-7G 7 <br /> SIGNED TITLE- � I �✓ �tJr I /t-cy� DATE 14 2 <br /> �O <br /> T <br /> F <br /> EPARTMENT VSE QfNLY <br /> Application Accepted By Date Area Employee ID <br /> Final Inspection By 9('a.0 SNknCJ_t` M — Date 1 ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PE SC Received c # Amount Permit/ <br /> Code INFO By as emitted Datep� Service Request# Invoice# Permit ID# <br /> WNuqm42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />