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WELL/PUMP PERMIT /10wfW Auel- <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL (2A09 953-7697 FOR INSPECTIONS <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 176 <br />$- I'OW� S460Ar�MP-470 <br />f CrrY/L/P�� <br />952Y1 <br />CROSS STREET � 0- /W <br />CFAAr R•Y APN OSp � 146 <br />-112- PARCEL SIZE Iii• S <br />LAND USE A' PPPL"ICATTIIONC# <br />OWNER NAME I mslo c <br />X-rrm 6A <br />PHONE i��G� T-ts- 57 <br />OWNER ADDRESS ?01 <br />q 7 3 <br />CRY/STATEILP L,0 eA 1024 7 <br />-&PX <br />y 1 <br />CONTRACTOR AIT-LAZZ - Kw 4l., s A roe. • <br />W <br />CONTRACTOR ADDRESS 7�`S-,b <br />(wNQv�fTR�Rt-- r7 �'�� <br />CRY/STATEMP <br />t_PHONE � A372-�d3� <br />_"• SA�0 e^�'ff gS`QJ <br />SUBCONTRACTOR V'! ^� <br />.U�lLtrd A(iT <br />PHONE -6g!;j T(qj-?7,*:% <br />ADDRESS //J) <br />SU13CONTRACLT, <br />�tOR A401 'I %AVr 'j>QIVIEr <br />CITY/STATE/ZIP <br />6,4L•T, cA Z <br />LICENSE C-57 'J C-01 <br />.�S <br />❑ D-09 J Other <br />NUMBER 7zo4oy <br />a9S6,? <br />E%PIRATION DATE T <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE J Domestic/Private 1_1 Irrigation/Agricultural ❑ Industrial .J Water Quality Monitoring XSoil Sampling/Characterization <br />i Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK J New Well l Replacement Well a Well Alteration/Modifi-tion J Other <br />i Monitoring Well(s) # of wells Soil Borings) _ _ a of borings XGeotechnical 4� II of borings <br />I Out -0f -Service Well J Out -Of -Service Well Renewal J Cross -Connection Repair (DI _ Dy) <br />I New Pump U Pump Replacement -I Pump Repair 1 Raise Well Casing <br />pilling Method I Mud Rotary a Air Rotary Auger I Cable Tool I Push Point : i Other <br />•oposed Well Depth /0-10 It Excavation i0 in diameter Open Bottom I 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 bag/5-f0 gal water) Sand Cement sack mix17 gal water <br />,.1 Bentonite (20% solids) �Sl Other SOf6 4017-W46if <br />rout Placement Method a Pumped 'Free Fall Other A Retardant / Accelerator (name) <br />PEDESTAL�/ Installed By �J Driller :. Pump Contractor I Other <br />/` _l Concrete Pedestal _0mensions: Width It Length ft Thick in _J Christy Box Stove Pipe <br />PUMP y U Submersible -1 Turbine 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. 1 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 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED TITLE F)fVJV r F."416(1:{M1 DATE 114 h t. <br />DEPARTMENT USE ONLY <br />Application Accepted By V r Date Area � f I_ U � I Employee ID# <br />Grout Inspection By Date I SPECIAL Well Permit <br />Pump Inspection By Dale I I WAIVER Received <br />Soil Boring 190pection_B# s__/ , Opts r Constructed Well Depth n -r -a 4 ft <br />EHD 43-06 8/01116 <br />WELL /PUMP PERMIT <br />PA <br />JqN <br />sAN�O ®� Zo1fJ <br />NEA ��/ROl� COU <br />TN <br />67p;! COU 7Y <br />d <br />