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*� A4 WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT Al �f� % <br /> CALL 209 953-76/97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 35NJOB ADDRESS x+252 /I/ <br /> �GCG �L -^� CITY/ZIP /f �0b S20_0 m <br /> CROSS STREET y_/Gv1 Z{� �►�f AP. ®� 0� �c DARCEL SIZE LAND USE APPLIICATION#^ A <br /> OWNER NAME AR ,PGS Ii'I/�`I PHON�Ey��y�7/.^�`�l/� �b� U) <br /> OWNER ADDRESS o?LIZ y dL MALI q9 F�j, y� CITY/STATE/ZIP Amli= e-A z_z / <br /> CONTRACTOR 16 ey ei /!G/ //7C. PHONE 77Z.x" 2 7 5'� <br /> 2 // r <br /> CONTRACTOR ADDRESS �� g?< /3� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 El C-61 0D-09 ❑Other NUMBER D7f�' EXPIRATION DATE e!!�- <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)E,Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural []industrial E]Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK /gNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> [I 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 /> %New Pum []Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method fill Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool []Push Point ❑ Other <br /> Proposed Well Depth �ft Excavation /Z in diameter []OpenBottom XGravel Pack/Gravel Size 3 i in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_L in Thickness/Gauge/ASTM Sched 2/ ❑Steel Plastic [-]Stainless Steel []Other <br /> Grout Seal Depth /DO ft ❑Neat Cement(94 lb bag/5-10 gal water) Sand Cement �� 3 sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method 9Pumped []Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller E]Pump Contractor ❑ Other <br /> Concrete P destal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine [-]Other HP Pump Set /_ �2 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 /> MINI 4 HOE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE /lG�iDATE <br /> i <br /> TY <br /> ENV R Nb E ANT <br /> LT - <br /> DEPARTMENT USE ONLY <br /> _ l � <br /> Application Acc;epied By a� I Date 1O �y _ Area '"� 'q Employee iD# <br /> Grout Inspection By Date Z _Z,w—;' ❑ SPECIAL Well Permit <br /> Pump Inspection By Date -7 ZWAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS�-TS.S Ve <br /> PE SC Received Check#/ Amount Permit] <br /> Codes Info Cash Re ifte Date Service Request# Invoice# Well ID# <br /> y (,6 411d0 1 .-17, <br /> L139 ) 41S-0 Iv I Ip I ti It <br /> 9 3q,2 470 j 1I II <br /> �jvo s D <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />