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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-REFUNDABLE PERMIT Zq_ (i CALL (209) 953-7697 FOR INSPE TI NS , EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ` CRY/{ZIP J DV'N 957 % -A- <br />CROSS STREET W • V I tA" VST. (Ww tom- �LAPN 0%'7 - �� V ZPARC EL SIZE 1 LAND USE <br />/A AJPPPLLICATIOQN # <br />OWNER NAME 1/TI K� �• P15- /Vvc- PHONE / Loq I 5�� <br />OWNER ADDRESS �( ��"�74c,✓/ "� ``O2^I' CITY/STATE/ZIP LdOI `'CCA 957-1(2. <br />CONTRACTOR _ �lAL.L-1°rL ii - r-•Vl H-1_ S r'lysOG. PHONE 31 -n -113y <br />CONTRACTOR ADDRESS JD -,C> <br />T n('N 6Li'5-TTL FRIG ) W D CITY/STATE/ZIP W ES 7- / GA t 95 <br />SUBCONTRACTOR y � -`r USI LI�r1 1LL(rs�1, I A(C-- {, r� PHONE <br />SUBCONTRACTOR ADDRESS I113 g1,Ar-K- M(t-5T bR-• CITYISTATE/ZIP(,. yr/ Gni' Z,0,6,3-2. <br />C-57 C-61 '.I D-09 '_/ Other NUMBER /ZO`117'f" EXPIRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE . i Domestic/Private . I Irrigation/Agricultural ; Industrial Water Quality Monitoring Soil Sampling/Characterization <br />i Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK i New Well I Replacement Well I Well Alteration/McHievation I Other <br />iMonitoring Well(s) #of wells itBoring(s)_ _ ft of borings Geotechnical 2 #of borings <br />I Out -Of -Service Well Out -Of -Service Well Renewal i Cross -Connection Repair <br />New Puma 1 Pumo Replacement . Pumo Repair .1 Raise Well Casino <br />Drilling Method Mud Rotary Air Rotary Auger I Cable Tool Push Point I Other <br />Proposed Well Depth C� ft Excavation (o �" in diameter I Open Bottom I Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casir9ktEfameter _ in Thickness/Gauge/ASTM Sched ; Steel I Plastic Stainless Steel Other <br />Grout Seal Depth ft .Neat Cement (94 lb bag/5- 10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free all Other «� `r Retardant / Accelerator (name) <br />PEDESTAL Installed By i Driller Pum Contrac r I Other <br />Concrete Pedestal iDlmensions: Width Ift Length ft Thick in J Christy Box Stove Pipe <br />PUMP Submersible, i 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 2�4�11j`t ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95? -7617 <br />SIGNED _ TITLE �yJ �-'1 I� DATE �I <br />DEPARTMENT USE ONLY <br />Application Accepted By4A Date (1 Z Area t, Employee ID# <br />Grout Inspection By Date SP Cl <br />ell Permit <br />Pump Inspection By A A A ) Date Tr W VER Re..ived <br />Soil Boring Ins ction By <br />COMMENTS <br />Date <br />Well <br />y <br />D <br />A <br />In <br />N <br />EHD 43-O6 6/01/16 re(, L" -ELL/PUMPPERMIT <br />� <br />= <br />W <br />jFM. <br />�9i�'� <br />_iceL�•�i�iei"/filGlJli1(ir1'/�G'�i7� <br />ll- <br />0ZtY <br />W <br />ElJ <br />C%j <br />o <br />Z Q <br />s Z w <br />�J <br />Ii. <br />M <br />EHD 43-O6 6/01/16 re(, L" -ELL/PUMPPERMIT <br />� <br />= <br />W <br />jFM. <br />7 <br />CV <br />ll- <br />0ZtY <br />W <br />ElJ <br />C%j <br />o <br />Z Q <br />s Z w <br />�J <br />Ii. <br />M <br />U) .Z <br />j p {k 1'0 <br />6(((vrel-q <br />fCj pvvle <br />ar:t 4 <br />