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r <br />WELL/PUMP PERMIT ��-Ttf PL_ <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 2w0A9 953-7697 FOR INSPECTIONS <br />EXPIRES 11 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1G� iShP0AAF,,70 <br />//Q�/'�!1 <br />M CITY/ZIP <br />LD�J� 46"L <br />�� <br />1 , <br />CROSS STREET W • C49" 1 AJL%j BLJD APN VM - 146 -5'2--PARCEL <br />�/ <br />SIZE Alf <br />LAND USE APPLICATION # <br />OWNER NAME M IAtjPf4 PC—,eAs-A <br />PHONE (9��) 9�rs- <br />u <br />OWNER ADDRESS P ��p.� -711 <br />/ n5C357 <br />_ CITY/STATEIZIP YV��p / (',/f -11; 2,Y7 <br />CONTRACTOR WA_V`LAGC —A IC6�t.4L. A AjJoG • <br />PHONE <br />CONTRACTOR ADDRESS F+fa jN4%4j r�1N:► AL -J& <br />CITY/STATE/ZIP <br />�r �3�I <br />SAL eA q5&QJ <br />w <br />SUBCONTRACTOR <br />PHONE _P0 �S� <br />T`l17 <br />SUBCONTRACTOR ADDRESS 3LAC-9, -AAf-r MRIVF <br />CITYISTATEIZIP <br />6 -AL -T0 CA0Z <br />LICENSE kC-57 ::. C-61 J D-09 :.I Other <br />NUMBER%ZOQoy <br />ExPIRATIONDATE Oaks <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE J Domestic/Private J Irrigation/Agricultural J Industrial Water Quality Monitoring Xsoll 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 J Well Alteration/Modification J Other <br />i Monitoring Well(s) # of wells foil Boring(s) a of borings Geotechnical S 4 of borings <br />J Out -Of -Service Well i Jut -0f -Service Well Renewal J Cross -Connection Repair <br />!J New Pump IJ Pump Replacement a Pump Repair iJ Raise Well Casing ` J <br />Drilling Method I Mud Rotary J Air Rotary Auger a Cable Tool J Push Point ..I Other <br />Proposed Well Depth AV -20 It Excavation (o in diameter J Open Bottom a Gravel Pack/Gravel Size in diameter <br />_I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel !J Plastic Stainless Steel J Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag15-10 gal water) J Sand Cement sack mix/7 gal water <br />J Bentonite (20% solid-% V Other SDN. GMT77A1 0 <br />Grout Placement Method a Pumped A'ree Fall ;J Other _I Retardant / Accelerator (name) <br />PEDESTAL Installed By .J Driller Pump Contractor Other <br />u Concrete Pedestal JDimensions: Width ft Length ft Thick In a Christy Box . i Stove Pipe <br />PUMP _j Submersiblei.J Turbine J 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 />MINIMUj&a4,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953,-7697 <br />EPARTMENT USE ONLY % �j <br />Application Accepted By 'iT_)_'Date �) J Area / LL J' Employee 0#�j <br />Grout Inspection By ��,��/��,Date i-� SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date _ Constructed Well Depth <br />EHD 43-06 W01/16 WELL /PUMP PERMIT <br />elven <br />04 2010 <br />>U1N COUNTY <br />pARTMENT <br />