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I <br />WELL/PUMP PERMIT <br />SAN JOAQUIN C UNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNIJABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS,.'+ _ CITY/ZIP(%IOQ�--- q.7J <br />CROSS STREET <br />�//� •/I��-•�t' AAPPN C '� PARCEL SIZE —//0 --LAND USE APPLICATION # <br />OWNER NAME /ftbq��'/f/as om^I � �JW cT-— PHONE <br />OWNER ADDRESSZO30 ' 5r ewa IV CITY/STATE1ZIP/ 2� <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITYISTATEIZIP_ <br />SMONTRACTOR PHONE /�--57 3/3_ ( OD <br />3MONTRACTOR ADDRESS J� / GMOO CRY/ST(ZI <br />TATEP r <br />�r�-' `^` `t (� <br />LICENSE XC -57 C-61 0-09 Other NUMBER " EXPIRATION DATE '-31—���a <br />DOMEsnc 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 />It 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 [I Soil Boring(s) # of borings xGeotechnical 2— <br />Out-Of-Service <br />Out -Of -Service Well D Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump ] Pump Replacement D Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary f1 Air Rotary Auger Cable Tool Push Point Other_ <br />Propqkt0jW Depth 57) Excavaton y •• in diameter I Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing _ in diameter / Conductor Casing Depth _ft <br />Well Casing Diameter_ in Thickness/Gauge/ASTM Sched _ _ Steel Plastic Stainless Steel Other <br />Grout Seal Depth__4jnP_ft *111([4eat Cement (94 Ib bao-10 gal water) Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped X Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By G 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 It <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 />MINI UM �O ` gNCE NOTICE REQUIRED FOR INGG{77pp�^.FC IONS - PLEASE CALL (209) 953-7697 <br />SIGNED � / _ V� TITLE g / �r� �^_ DATE 11—,F-1-7 <br />P A M E N T nll <br />L Y <br />Application Accepted By te Area �Emp toyl <br />m#/ <br />Grout Inspection By _ Date SPECIAL Well Permit <br />Pump Inspection By _ Date WAIVER Received <br />Soil Borin Inspection B Date Constructed Well Depth ft <br />COMMENTS�f <br />PE SC Received Check#I Amount Date Permit/ Invoice # Well ID# <br />Codes Info B as Remitted rvice Request # <br />Sl 11 zv r -t r 4106 97 4,1 <br />EHO 4106 8/01116 WELL/PUMP PERMIT <br />'EIVIED <br />I u 201? <br />HEk,r,H <br />