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_1n l W dry n W <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-34210 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS ,/�/jE�X�P/IREES I YEAR FROM DATE ISSUED <br /> /i' A- r Ft'-A �� > m <br /> JOB ADDRESS CITYIZIP > <br /> ®� �Qti D <br /> CROSS STREET f $ 1�� PARCEL SIZE O�LAND USE APPLICATION#/J 0 <br /> r% DC �l N �� I '^ PHONE <br /> OWNER NAME <br /> OWNER ADDRESS ,./ �7 < H'f'e -//IJT CITYISTATEIZIP � l <br /> CONTRACTOR I PHOON1�✓�NE� J� /7��_ <br /> CONTRACTOR ADDRESS IAPP L� CITYISTATE/ZIP —5f x 'e* <br /> lam. f <br /> SUBCONTRACTOR r4 PHONE <br /> SUBCONTRACTOR ADDRESS _ CITYISTATEIZIP _. <br /> LICENSE -57 -61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:(]General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑IrrigationlAgricultural ❑Industrial ❑Water Quality Monitoring [-]Soil Sam plinglCharacterization <br /> [I Public Water System <br /> If different from Owner Wa er bystern Name Contack Name or one um er <br /> TYPE OF WORK ))&Tlew Well ❑Replacement Well ❑Weli Alteration/Modification [-I Other <br /> ❑Monitoring Well(s) #of wells ❑Snit Boring(s) #of borings ❑Geotechnicai #of borings <br /> ❑Out-Of-Service Well [I Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump [:]Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method, &ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth _27o0_rft Excavation /Z in diameter [I Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor asing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ef4. 1' El Steel flipPlastic []Stainless Steel ❑Other <br /> Grout Seal Depth ZrV ft [:]Neat Cement(941b bag15-10 gal water) ❑Sand Cement sack mix17 gal water <br /> 'Olilleentonite(20%solids) ❑Other <br /> Grout Placement Method japumped ❑Free Fall ❑Other ❑Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ump Contractor ❑ Other <br /> ❑Concrete Pedestal ensions:Width ft Length ft Thick in []Christy Box ❑Stove Pipe <br /> PUMP ubmersibieDTurbine ❑Other HP Pump Set ft Standing Water Level <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 ANCCyE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (249) 95 -7697 <br /> SIGNED �. _ I/",��/ - TITLE f - DATE O 1 <br /> i <br /> { <br /> aJ <br /> Ji <br /> ly A <br /> A el <br /> DE A R T M E N T S ff O N L Y <br /> Application Accepted By, � Date (( cJ l Area Employee ID#� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date m ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#I Amount Permit/ <br /> Codes Into S Cash Remitted Date Service_ Request# Invoice# Well ID# <br /> b - I b S 2_27 <br /> r5 7 <br /> t11 11911to M00 22`7 <br /> FHD 43-08 8101115 WELL/PUMP PERMIT <br />