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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-5420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7(197 FOR INSPECTIONS txNlKtb T YEAR FROM UATE ISSUE <br />Joe ADDRESS 6tN 4 Alf Xa.ln r1" I CITY/ZIP '�O GI57AT <br />CROSS STREETW • L i Aub 1 n f -?d • APN PARCEL SIZE � L NO USE APPLICATION #_ <br />OWNER NA 1E Tors C 1 � 1}L� c PHH'O�N.E+5�0-t Jg(,� Z Z <br />OWNER ADDRESS r�^�^ (Qi.C_i),J L1t DO CITY/STATE/ZIP OM1N-W`(.� 1i71"rp -i V <br />CONTRACTOR (�i-%COIL W�SVi1W"'J knC' PHON[CM. 652 -iI( g <br />J <br />11,1VQ (' �IGI ly -Dr � v It *YdITY/STATE/ZIP%a,,w�;i.'A- A 19 G <br />CONTRACTOR ADDRESS 3 <br />SUBCONTRACTORT+« <br />� <br />1PHONE(91643N - 47,01 <br />SUBCONTRACTOR ADDRESS Z 9D5 G e S V0 S CZ . CITY/STATE/ZIP L i /lO J K I Ct+ / Q S& `3 <br />LICENSE C-57 C-61 I.I D-09 - Othef NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING:. General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) U Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private I Irrigation/Agricultural Industrial ?:1 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 1.. Replacement Well El Well Alteralion/Modifcalion i r Other <br />❑ Monitoring Well(s) # of wells It Boring(s) 6— sof borings _ Geotechnical s or borings <br />❑ Out -Of -Service Well D Out -Of -Service Well Renewal ! Cross -Connection Repair <br />WELL CONSTRUCTION <br />Drilling Method i Mud Rotary L Air Rotary /Auger i Cable Tool Push Point Other <br />Proposed Well Depth IS It Excavation in diameter Open Bottom i:; Gravel Pack/Gravel Size in diameter <br />1. Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched �'. Steel Plastic U Stainless Steel Other <br />Grout Seal Depth IS ft ✓Neat Cement (94 Ib bag/5-90 gal water) Sand Cement sack mix17 gal water <br />-Bentonite (20% solids) C1 Other <br />Grout Placement Method _i Pumped I'Free Fall a Other Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller n Pump Contractor Other <br />Concrete Pedestal [0mensions: Width It Length fl Thick in Christy Box L Stove Pipe <br />PUMP Submersiblei..l Turbine Other HP Pump Set It Standing Water Level h <br />I HEREBY CERTIFY THAT 1 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 />J'jN'`IM_ ,tM 2�_y4,,yHn)OUR�AJl7�V�/�]yy�`E NOTICE REQUIRED FOR <br />IINSlPECTI,OINNS -PLEASE CALL (209) 953-769 <br />SIGNED / ^' VL ' ■ 1 /ISL � - TITLES I` + �. '-11 A� DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection ByL- <br />COMMENTS <br />TMENT U E /N Y <br />Date L <br />Date <br />Date L f <br />Date <br />y �R Q411'V X18 <br />yFAgR�M 041,�Y <br />T <br />Area �.Employee ID#_1" <br />SPECIAL Well Permit <br />I WAIVER Received <br />Constructed Well Depth <br />MUMT1:. <br />,i VWSURMWIMAIMUNTl�A! fEUMExTN <br />EHO 47-06 8101!16 �—r -/ -) ���7 /� /�i'— WELL /PUMP PERMIT <br />