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WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468.3420 <br />N-KEFUNDABLE PERMIT` <br />GALL (ZU9) V*J-7697 FOR INSPECTIONS <br />EXPIRES 9 YEAR FROM DATE ISSUE[ <br />ADDRESS <br />I <br />'�y <br />{ <br />(rlp,,. Ay-,AGnc— <br />CnY/7JP <br />//,�,,33 <br />SS STREET L-crx j rr <br />�+'rfGi/� <br />APN I1 J _ 130 I <br />PARCEL SIZE <br />LAND USE APPLICATION # <br />IER NAME s c o <br />rl l.S i, <br />k' ie- C0. tt, ct4r,.� \ <br />PHONE LOCI <br />' <br />IER ADDRESS 33 <br />vJ. <br />7 Uf(IN <br />CRY/STATE/ZIP <br />S-toc K-+G:l <br />/ C�7� / 157 <br />TRACTOR V 4-W <br />Dt•.11I��y\^tet <br />PP^HONE .201 <br />/�,D,� <br />'— SVI — 1 k -)O <br />TRACTOR ADDRESS 1133 <br />bl"'r- K r\LI rS � D- rp. <br />CRY/STATE/ZIP <br />L3 -t+ / ( <br />6- / gj('� <br />ADDRESS <br />C-57 ❑ C-61 ❑ D-09 ❑ <br />CRYISTATE/ZIP <br />NUMBER 72-ClIc 1 <br />PHONE <br />EXPIRATION DATE y — 3 L`) -- i 8 <br />DOMESTIC WELL SAMPLING: !- General Mineral/Coliform Bacteria (4391) I.I Dibromochloropropane (4392) a Arsenic (4393) <br />INTENDED USE ❑ Domestic/Pdvate ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells )( Soil Boring(s) I # of borings ❑ Geotechnical #of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />u <br />1 ­ <br />rump u rump mepiacement u rump mepair u Kalse vvee Gasing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary X Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth)Sft Excavation 'R in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth it <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 2 5 it Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall X Other I ft,n � ❑ Retardant I Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width it Length it Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP ❑ Submersible[] Turbine ❑ Other HP Pump Set it 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 />MIN���iJ1A 24 OUR!VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />�( SIGNED ```'�^ TITLE 1%7014;ne e. DATE 11 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />DEPARTMENT USE ONLY <br />Date Area Employee ID# <br />Date ❑ SPECIAL Well Permit <br />Date ❑ WAIVER Received <br />Date Constructed Well Depth ft <br />PE Sc Received Check#/ Amount Permit/ <br />Codes Info B Date Cash Remitted Service Request # Invoice # Well ID# <br />EHD43-0e MIMS WELL PUMP PERMIT <br />