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C0 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IVUIV-KEFUNDABLE PERMIT (;ALL LUy yOS-ft)Uf FOR INSPECTIONS tAlllKtb l YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />Application Accepted By <br />Date <br />CITYIZIP DUh �� vV� tgLGl <br />CROSS STREET W, • _ ^ <br />OWNER NAME X11!`" 1 <br />OWNER ADDRESS I � <br />1 ^ APN <br />v �� V L I <br />r n - AA. <br />li 0� O I <br />F�AiRCE SIZE I • J S LAND USE APPLICATION 70 <br />rN <br />:J r7 G �///PHONE ���, /���� Ian' (()' )(tG'� <br />CITY/STA7EIZIP I <br />[ 0.G(/, & I IJ / � I <br />CONTRACTOR <br />I <br />-Aff <br />L <br />O E <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />(� { <br />v^/1) O�/�{' <br />'V (/ ' <br />C <br />` <br />CITYISTATE/ZIP ��Q/• G1.If GV U l/ I IJ�� <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />3 <br />Wive, <br />CITY/STATE/ZIP <br />LICENSE C-57 <br />C-61 D-09 Other <br />] /yy <br />NUMBER Q 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 XSoil Sampling/Characterization <br />Public Water System <br />If different from Ovmer. 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 X t7tr a of bo ings Geotechnical # of oorings <br />Out -Of -Service Well (Jut -Of -Service Well Renewal Cross -Connection Repair ('Z) } t l3� �' <br />New rump Hump Ke lacement Hump Ke air Kalse Well uasing t R f <br />WELL CONSTRUCTION I <br />Drilling Method u�l Rotary Air Rotary )C,Auger Cable Tool Push Point Other <br />lLi f <br />Proposed Well De Wt 9 -0 -So ft Excavation _!� in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />r <br />y070i r"1r( Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />L✓ 1 Rv <br />Grout Seal Depth 1 t�Neat Cement (94 /b bagl5-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids <br />Grout Placement Method Pumped &ree Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: 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 />MU R ADVANCE NOTICE REQUIRED FgRINSPECTIONS - PLEASE CALL (209) 953 7697 <br />SIGNED TITLE !f'KJ4M l���M DATE <br />Area G Employee ID# 4 4 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />H <br />Z Z <br />w <br />OFF - <br />U Z <br />U, <br />1 ZMa <br />z <br />9W <br />PE <br />Codes <br />DEPARTMENT USE ONLY <br />Application Accepted By <br />Date <br />Grout Inspection By4h-L <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />Area G Employee ID# 4 4 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />H <br />Z Z <br />w <br />OFF - <br />U Z <br />U, <br />1 ZMa <br />z <br />9W <br />PE <br />Codes <br />SC Received <br />Info Cash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />3 <br />EHD 43-06 8101116 WELL /PUMP PERMIT <br />