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P✓� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 9553-77697 FOR INSPECTIONS C EXPI`R.ELS,I YEAR <br />,1tFROM <br />CDATE ISSUED <br />JOB ADDRESS 1 r IV CITYIZIP J CFI W i (7 1 <br />Ja I 'A ILL ISo�3 )VA <br />CROSS STREET CO.— -`{.j OG AP1(N'` PARCEL SIZE� /) LAN USE A^yPP/LlICATION # 't II p <br />OWNER NAME CO-'� �t..I1. •`r JWAv�/MAN �L(M •�/J/Y NE _�VUI(I y <br />H <br />OWNER ADDRESS IJ ` 1 MA +v(,t+o v (A 9 J AI <br />h 1 11 ti�r�r1C 1 e- r PHONE <br />-11(;-SVi Q�t <br />ADDRESS' <br />IA1 �(�(1 /^ L (J��. CITY/STATE/ZIP / I 1 //,��' NIw/y�� (/J�1� <br />rOR V i (A) 1/r1 /.�� PHONF -1' 1 W 1_??V D <br />SUBCONTRACTOR ADDRESS J O UIP I f Ll..t�K— U -U-4- (jr kYT, CITYISTATE/ZIP <br />LICENSE XC -57 C-61 D-09 Other NUMBER � )f7C I Qq EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 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 Wells) # of wells ><Soil Boring(s) I n of borings Geotechnical n of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />)rilling Method Mud Rotary Air Rotary >e -Auger Cable Tool Push Point Other <br />r <br />proposed Well Depth IS Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth IS' ft 7GNeat Cement (94 /b bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />3rout Placement Method Pumped Y Free Fall Other Retardant / Accelerator (name) <br />PEDES r /^ Installed By Driller Pump Contractor Other <br />�VfF'1 Concrete Pedestal Dimensions: Width It Length ft Thick in Christy Box Stove Pipe <br />PUMP Submersible 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. 1 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 />MINIMUM 24 H UR A�D/V�ANCE NOTICE REQUIRED FOR1/I�NSP,ECTIO S -PLEASE CALL (209)953-7697 <br />SIGNED 1 - 9 TITLE 'J �I Q' ��� DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring InTel..o7By <br />COMMENTS I / / <br />DARTMENT SE N Y <br />Date Area Employee ID# j/t/Lr)f(/j <br />Date ell Permit <br />Date WAIVER Received <br />!1 Date Constructed Well Depth ft <br />EHD 43-06 8/01116 WELL/PUMP PERMIT <br />