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itis � 2-i� in�r�\ 5��►� 2��-�- �� I��r—� �� v/ <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 1 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _Ln <br /> JOB ADDRESS .� [ Ei�T1 ) S CITY/ZIP L / J' jl - <br /> y� Qm <br /> CROSS STREET ;;% <br /> 1 f��%✓ !! 1 �4/ APN I !-Ito-7 / `� D <br /> /�i PARCEL SIZJE� LAND USE APPLICATION ] X <br /> 7 m <br /> OWNER NAME l �- i /n/'V'frl /�p��/i��i G�• �T& . PHONE J J/J , Ir Z I ��� P <br /> OWNER ADDRESS J��t CITY/STATE/ZIP�j � (/T' <br /> CONTRACTOR /\(� PHONE J T` 72, <br /> CONTRACTOR ADDRESS �j �f ) 7 CITY/STATE/ZIP re, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 7 ❑C-61 ❑D-09 ❑Other NUMBER ! 5�)5 EXPIRATIONDATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ;,ebomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name Gontact Name or Phone Number <br /> TYPE OF WORK Jew Well ❑Replacement Well ❑Well Alteration/Modification E]Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring #of borings s) ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal []Cross-Connection Repair <br /> ,wvew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method $Wud Rotary E]Air Rotary ❑Auger E]Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation i -2– in diameter F]Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter A in Thickness/Gauge/ASTM Sched L ❑Steel Plastic L]Stainless Steel F]Other <br /> Grout Seal Depth LLY� ft ❑Neat Cement(94 Ib bag/5-10 gal water) 96 and Cement %u; J sack mix/7 gal water <br /> ❑Bentonite(20%solids) F-1 Other <br /> Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller ❑Pump Contractor ❑ Other r <br /> L]Concrete Pedestal dimensions:Width 1 ft Length�—ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP f5ieubmersible❑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 COUNT`;' ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE ZJ 7 <br /> v <br /> 10 <br /> 4r T <br /> /1 <br /> t <br /> I � � <br /> D PARTMENT SE N L Y <br /> Application Accepted Date Area Employee ID# <br /> Grout Inspection Date �- ❑ SPECIAL Well Permit <br /> Pump!nepectic„By ^�� � � Da t: LJ 'r"diaiVEii R@G@IVeti <br /> Soil Boring Inspection By D Constructed Well Depth ft <br /> COMMENTS A in t4 <br /> _ L <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Co.es Info B Cash Remitted Service Request# <br /> "C <br /> S <br /> I - <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />