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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 (4, CALL (209) 953-7697 FOR INSI <br />JOB ADDRESS +/fl6��Gronnn�" Pw'=-)/y1 u' <br />CROSS STREET tn-�� et APN `� 0 { —I%I07-3 P) <br />OWNER NAME DO Y,LCl.1�`��gY�Yw <br />OWNER ADDRESS♦v� t1�� S <br />CONTRACTOR II' uI , c W }A, I I �. <br />CONTRACTOR ADDRESS -39 "1 Q1 r 1 �/[ n by, <br />SUBCONTRACTOR <br />CI'/ZIP <br />',CEL SIZIr%/ !/ LAND USE APPLICATION It o <br />.� yp <br />PHONE�G-� i{'�gJ�4 <br />CITY/STATE/DPirS e -*I t, 44 , <br />'"l <br />PHONE Z+' ` - �{� <br />CITYISTATFJZIP ESC CA) <br />J <br />A) . �,l� 1 3 ^'Z <br />PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE17JP <br />1' <br />LICENSE )(C-57 C-61 D-09 Other NUMBER <br />EXPIRATION DATE 1 I <br />DOMESTIC WELL SAMPLING: General Mineral IC ol iform Bacteria (439 1) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private 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 weds L Sod Boring(s) if of borings Geotechnical If of borings <br />Out -Of -Service Well L Out -Of -Service Well Renewal Gross -Connection Repair <br />)(New Pump Pump Reolacement _ PUMD Repair Raise Well Casino <br />Drilling Methodx Mud Rot a/ry Air Rotary a Auger t Cable Tool Push Point Other <br />Proposed Well Depth Z tP Excavation �_ in diameter n Bottom ?(Gravel Pack/Gravel Size in diameter <br />CorWucI CasfngI in diameter / Conductor Casing Depth R <br />Well Casing Diameter f in Thickness/Gauge/ASTM Sched. Ur Z 1 SleeLX Plastic Stainless Steel Other <br />Grout Seal Depth j 0Z It Neat Cement (94 Ib bag/5-10 gal water) }K Sand Cement]%+3 S)= S I U{ Hack.W7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Metho(IXPumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Duller (Pump ContractorOther <br />Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP )kSubmersible Turbine Other HP Pump 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. 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 />MINIMUM4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209J�953-/i),�691 <br />SIGNED �GL�l� TITL.'� 1711--* L� r DATF�e f f <br />to <br />D <br />A <br />N <br />DEPARTMENT/ <br />/O /Y 5L) <br />Application Accepted By Date L 0 �` 1 7 Area / / / { Employee ID# <br />Grout Inspection By Date -j/,A0S/(Z SPECIAL Well Permit <br />Pump Inspection By Date - X WAIVER Received <br />Soil Boring Inspection By Date fi - Constglcted Well Depth <br />COMMENTS W <br />PE Sc Received Check#/ Amount Date <br />Codes Info B Cash Remitted <br />r— <br />Z -A W <br />LLI <br />N <br />OZ� <br />C", <br />W <br />0 <br />Z W <br />OQ <br />P- - <br />2 <br />12 <br />IX <br />Q <br />Z <br />�WW <br />U) _ <br />DEPARTMENT/ <br />/O /Y 5L) <br />Application Accepted By Date L 0 �` 1 7 Area / / / { Employee ID# <br />Grout Inspection By Date -j/,A0S/(Z SPECIAL Well Permit <br />Pump Inspection By Date - X WAIVER Received <br />Soil Boring Inspection By Date fi - Constglcted Well Depth <br />COMMENTS W <br />PE Sc Received Check#/ Amount Date <br />Codes Info B Cash Remitted <br />Permit/ Invoice# WellID# <br />Service Re uest# <br />r r,Cra <br />W-61 i � <br />L;j <br />C", <br />EH04306 MV16 <br />WELL (PUMP PERMIT <br />