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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT / t� CALL 209 953-7697 FOR INSPECTIONS / tEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �^3..F{C) lJc7%moi `l,s, �Vn/G 4 [JI Z CITY//7�1)P4 J e,,-e/f�f <br />CROSS STREET JTto l , r 1 APN r`�'�/ _/_! O'" 3 yPARCEL SIZE & Z LAND USE APPLICATION# <br />OWNER NAME r-1 y�ePHONE�fi� �rrg3 y4Q ��}p V <br />OWNER ADDRESS �(DO (t�r`Z.�S T 1A�. CITY/STATE/ZIPIr...J 4,Of'UYry�,'�R'(�/r ��6(..��/'� <br />CONTRACTOR ) t`'' W D I PHONE C1\ <br />y[�Vr�./} <br />CONTRACTOR ADDRES SCITWSTATEIZIP ESC. eA� 5 Z Jpa <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/^S'1TATElLP <br />LICENSE C-57 C-61 D-09 Other NUMBER i \ 1 1 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE Domestic/Pnvate Irrigation/Agricultural a 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 54 Replacement Well L Well Alteration/Modification Other <br />Monitoring Wells) # of wells L Soil Boring(s) # of borings Geotechnical <br />Out -Of -Service Well L Out -Of -Service Well Renewal Cross -Connection Repair <br /># of bongs <br />Drilling Method < Mud Rota/�ry Air Rotary L Auger 1 Cable Tool Push Point Other <br />Proposed Well Depth lP Excavation 1Z'�i in diameter p'pen`Bottom AGravel Pack/Gravel Size " in diameter <br />Conduct r Casing asinft <br />in diameter / Conductor Cg Depth \ <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched��Qr Z) SteeLX Plastic Stainless Steel Other <br />Grout Seal Depth jOC..) ft Neat Cement (94 lb bag/5-10 gal water) xSand CemenA �3 S = S Lel klack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement MethodXPumped Free Fall Other Retardant I Accelerator (name) <br />PEDESTAL Installed By Driller (Pump Contractor Other <br />(Concrete Pedestal Dimensions: Width ft Length ft Thick n Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set 0 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 4 / UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209//g953-/}7;69{)7 <br />SIGNED / (/4-- . TITLI�dn%%G C'/ V r DATV-4 f / <br />to <br />D <br />m <br />m <br />N <br />DEPARTMENT US O LY <br />Application Accepted By �%j Dale 10 / <br />�I Areae Employee ID# <br />Grout Inspection By Dale AL Well Permit <br />Pump Inspection By Date "1,". r WAIVER Received <br />Soil Boring Inspection By DateConstrpcled Well Depth' 2-25- N <br />COMMENTS ��� rt..�, !! 4d:!Z1 Z44 <br />PE Sc <br />Codes Info <br />Received Check#/ <br />8 Cash <br />t- <br />3 <br />p <br />ZJU.t <br />LU <br />® <br />QZLC <br />-- <br />W <br />Z 5-; n <br />LLj <br />000 <br />U) <br />DEPARTMENT US O LY <br />Application Accepted By �%j Dale 10 / <br />�I Areae Employee ID# <br />Grout Inspection By Dale AL Well Permit <br />Pump Inspection By Date "1,". r WAIVER Received <br />Soil Boring Inspection By DateConstrpcled Well Depth' 2-25- N <br />COMMENTS ��� rt..�, !! 4d:!Z1 Z44 <br />PE Sc <br />Codes Info <br />Received Check#/ <br />8 Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />3 <br />l (9v2.. <br />c <br />r > <br />L <br />EHD43-06 8016 WELL,PUMP PERMIT <br />