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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 489-3420 <br />JOB ADDRESS V1 Y! Q V CITY/ZIP I <br />CROSS STREET `�"J,' S ! /J+V u / Rand# A{/P�I C. ?,1 Z) J DOPARCEL S12E,LAND USE APPLICATION # <br />OWNERNAME C T G ` PHONE (� z <br />OWNER ADDRESS 1� q I 1 l CITY/STATEILP �r a o `r J 7� <br />CONTRACTOR 1�. L�I[I�r(7 L1(rC.C.f� T ,,,�1 / PHONE! /� /'7 (r-iI s/� <br />CONTRACTOR ADDRESS L(/OI / Y``iJf/�1+%`'L� /-. (D0 CITY/STATEIZIP 'Sba VH, ej szo <br />SUBCONTRACTOR �.di{ %'l l(L�A r W/YM/1jO7QOI'�CVs - ✓y . PHONE F10 -�r3.5 2 —%.�(/p��7i�l�y <br />SUBCONTRACTOR ADDRESS W # Wd 4& Ci • CITY/STATE/LP k7 ���'Y/ p ^,.(„'f' /�/ P <br />LICENSE 4 G-57 ❑ C-91 O D-09 ❑ Other NUMBER, &q� EXPIRATION DATE l� 3V 1_`�- !f - <br />DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE D Domesde/Private D Irigatton/Agdcultural D Industrial D Water Quality Monitoring Sall Sampling/Characterization <br />D Public Water System <br />If dllrorenl from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK D New Well D Replacement Well n Well Alterallon/Modi9cation 0 Other 1 <br />D Monitoring Well(s) # of wells ❑ Soil Boring(s) eorbcrings y Geotechnical # of bonn94 <br />D Out -Of -Service Well D Out -Of -Service Well Renewal D Crass -Connection Repair <br />Drilling Method D Mud R tary ❑ Air Rotary ❑ Auger ❑ Cable Tool 4 Push Paint D Other <br />Proposed Well Depth_ft Excavation In diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />D Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter_ in Thicknes /Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 4 Neat Cement (941b bag/5-10 gat water) ❑ Sand Cement sack mixq gal water <br />D Bentonite (20% solids) U Other <br />Grout PlacementMethoddd Pumped ❑ Free Fail ❑ Other D Retardant/Accelerator(name) <br />EDESTA Installed By D Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal 0Dimensions: Width ft Length ft Thick In D Christy Box D Stove Pipe <br />UMP ❑ SubmersibleD Turbine ❑ Other HP Pump Set it 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />Grout Inspection By Dale ❑ SPECIAL .11 Permit <br />Pump Inspection By Data ❑ WAIVER Received <br />Soil Baring Inspection By Date ,,5 R Constructed Well Depth It <br />COMMENTS <br />PE <br />Codes <br />41) <br />SC Received Check#/ Amount <br />Info B Date Cash Remitted <br />O AA -2— q4lc <br />1364 <br />Permit/ Invoice # Well ID# <br />Service Reauest# <br />�oa385L 1 <br />EHD 43 06 —mv d 4114118 WELL IPUMP PERMIT <br />