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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 -REF NDA LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />r LAJ <br />JOB AD ESS `. 1 ��(r` .r , Ma O)V��q OV` 7~CITY/ZIP Otl, (S <br />CROSS STREET NW C11 i\eX- ( N4t`V A PNO��DL1—It,]O' -3 PARCELSRE, ��ANDI APPLICATION# <br />OWNER NAME A' • ` .r�V�/F]HONE / (-.SSD- 255�-y 'A <br />27 <br />OWNER ADDRESS - /v. 1F(K T tzP /tet OrMrsar� r//�i7./���- -/y(JC/ <br />1 2 <br />CONTRACTOR VAI PHONE (mac. 9) 769 — Toa <br />CONTRACTOR ADDRESS 61,r.Ahur5 CrfY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CrtYj//SS�TATE/ZIP <br />LICENSE X - LCJ C-57 C-61 D-09 Other NUMBER 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 )(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) # of borings )(Geotechnical �� of borings <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casinq <br />Drilling Method Mud Rotary Air Rotary )(Auger Cable Tool Push Point Other <br />Proposed 1�llllie Depthf �_L_fl Excavation (ter / in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />r I /!y 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 XNeat Cement (94 Ib bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method )(Pumped Free 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 />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -//PLEASE CALL (209)/953-7697 ^ d <br />SIGNED TITLE r -s T- 1T , S,',fCr h,1A�1r DATE 6_20 0 <br />✓ 15 <br />0 <br />Woo <br />W C'V <br />N <br />C <br />W <br />LL <br />= C: <br />U. <br />W <br />Q x <br />x CL <br />Z <br />LU <br />✓o N�9 FO <br />?ode <br />Rp N <br />y�F qR�N gcti�Y <br />MFNT <br />Area EmployeeID#� <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />���F1.1��►llL,'JI��•��'�Il�lPl�i�l��lG11�Z,S'I.U�1� <br />EHD 43-06 revised 4/14/18 71 4/WELL /PUMP PERMIT <br />PA TMENTT USE 0 <br />Application Accepted By <br />Date 70 <br />Grout Inspection By <br />Date <br />Pump Inspection By <br />Date <br />Soil Boring Inspection By AINDate <br />COMMENTS <br />0 <br />Woo <br />W C'V <br />N <br />C <br />W <br />LL <br />= C: <br />U. <br />W <br />Q x <br />x CL <br />Z <br />LU <br />✓o N�9 FO <br />?ode <br />Rp N <br />y�F qR�N gcti�Y <br />MFNT <br />Area EmployeeID#� <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />���F1.1��►llL,'JI��•��'�Il�lPl�i�l��lG11�Z,S'I.U�1� <br />EHD 43-06 revised 4/14/18 71 4/WELL /PUMP PERMIT <br />