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WELL/PUMP PERMIT P /' <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLEE, PERMIT A' Q /�,, UALL ZU9 953-7697 FOR INSPECTIONS EXPIRE5 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS �CJ /y J J( I-jpivT r �� CITY/ZIP G(�IL C C S ✓� <br />,, <br />l�7 <br />CROSS STREET b t3 yLtJ. APN l ti o -d PARCEL SIZE , u, LAND USE APPL7IUTION # <br />A <br />OWNER NAME <br />10 <br />OWNER ADDRESS 0zs J. P <br />CONTRACTOR <br />L. dam.,/ - /II A 9 17 <br />Cr/STATE/ZIP kj C 9�D> <br />/ PHONE 1 -0g -307;b1 <br />CONTRACTOR ADDRESS go-- -T n6&t � L(/ ZLt/ CITY/STATE/ZIP C A 9s --w <br />SUBCONTRACTOR SL//�- PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE [;@C-57 ❑C-61 E] D-09 [I Other NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: [-]General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) [-]Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural []industrial ❑ Water Quality Monitoring 1)� 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 WSoil Boring(s) y # of borings Geotechnical # of borings <br />❑Out -Of -Service Well F-1 Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />U New Pump Lj Hump <br />WELL CONSTRUCTION <br />Hum <br />False vveii <br />Drilling Method ❑ Mud Rotary ❑Air Rotary Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth 10 ft Excavation 6? in diameter El open Bottom ❑Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thicknes uge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br />Grout Seal Depth ft #Neat qeRent (94 Ib bag/5-10 gal water) []Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) <br />Grout Placement Method ❑ Pumped Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft 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. 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 />MII)N�11� HO MANCE NOTICE REQUIRED FOR <br />,, INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �� TITLE �C r� O&0i(**1N� rs nuts+ DATE <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />T <br />1 <br />m <br />D <br />0 <br />v <br />M <br />m <br />u) <br />ur <br />M <br />PE SC Received Check#/ <br />Codes Info B Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01116 WELL /PUMP PERMIT <br />