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WELL/PUMP PERMIT <br />F.ON-REFUNDABLE <br /> -AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> PERMIT'' CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Ln <br /> JOB ADDRESS !1 7 / �� fry!) S CITY/ZIP �� 1 ��� m <br /> / // D <br /> CROSS STREET 1 ) J ;r3;� fl^ APN (` PARCEL SIZE LAND USE APPLICATION# 0 <br /> OWNER NAME mai �i} / / ]� UCJ� ��. i PHONE a 3o <br /> OWNER ADDRESS /�/�M /- / /c- (/� CITY/STATE/ZIP <br /> CONTRACTOR `-F13va -PHHONEzt- <br /> CONTRACTOR ADDRESS n-e 7Q CITY/STATE/ZIPs— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY�/SSTTATE/ZIP <br /> LICENSE7 ❑C-61 ❑D-09 Other NUMBER ( ► 5L?5 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDEDUSE „.i omestic/Private ❑Irrigation/Agricultural ❑Industrial [-]Water Quality Monitoring []Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner Water System Name (;ontact Name or Phone Number <br /> TYPE OF WORK &+New Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> jmzivew Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,�Oud Rotary ❑Air Rotary ❑Auger [:]CableTool []Push Point ❑ Other <br /> Proposed Well Depth2,6'j-:- ft Excavation �, in diameter ❑Open Bottom Wravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter h in Thickness/Gauge/ASTM Sched-Lx ❑Steel Plastic ❑Stainless Steel E]Other <br /> Grout Seal Dep&rL— � ft ❑Neat Cement(94 Ib bag/5-10 gal water) 96and Cement_, J sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall F]Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By driller E]Pump Contractor ❑ Other f <br /> E]Concrete Pedestal❑dimensions:Width l ft Length c7 ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP submersible❑Turbine ❑Other HPPump 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. 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 /> MINIMUM24HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE - ZJ - 7 <br /> t <br /> � yv <br /> N <br /> c <br /> Aj- <br /> 10 <br /> =�a`c <br /> Or 0W <br /> 1 � <br /> I <br /> ID PARTMENT SE N L Y <br /> Application Accepted i Date Area Employee ID# % '�✓1�� <br /> Grout Inspection Date - ❑ SPECIAL Well Permit <br /> P, . !nsspecticn By tJ n 0 Date 'i'" ,�A l l���' ❑ `AiVER Received <br /> J...r. N.......��vy <br /> Soil Boring Inspection By D Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> . <br /> SLAG <br /> I S ; <br /> EHD43-06 8/01/16 <br /> WELL/PUMP PERMIT <br />