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WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 • (209) 468.3420 <br />NON-REFUNDABLE PERMIT <br />GALL 209 953-7b97 FOR INSPECTIONS tAF9Kt5 3 T EAR FROM UATt ISbUtu <br />JOB ADDRESS <br />OV R �!4p CITY/ZIP SnCkTOAP I r2 to <br />((��/9/!f �JE.� <br />MA&CH <br />nGJAN <br />�% <br />E Dg1pD� 1 Z31LAND <br />CROSS STREET L -. <br />LA w APN r— PARCEL SIZE USE APPLICATION It <br />OWNER NAME S-tDCkTAN <br />UN1F16p sena •-ytS-il PHONE <br />qr <br />OWNERADDRESS 701 N- MAC1,JOW I Cr1Y/STATE/ZIP IT 0L I<1/0y~ CQ •lZ02- <br />CONTRACTOR V4LL4Ct-K-ML' ; Ag*ti TEI PHONE `TA)1 2 <br />j - <br />CONTRACTOR ADDRESS Ag7ip <br />C'.—/V.?'y <br />/wPLAT-Chn i�✓D- Crry/STATE/ZIP W115 �I,11196 40, CA W <br />SUBCONTRACTOR V 4' k% fl►21LLW6PHONE Cut •yq- 7To0 <br />SUBCONTRACTOR ADDRESS !X33 <br />$tAC1cN�te•M CITY/STATE/ZIP &"`r CA ?fb 3Z <br />LICENSEC-57 L C-61 <br />= D-09 J Other NUMBER 7210 4?W EXPIRATION DATE 00/iO <br />DOMESTIC WELL SAMPLING: i -i General Mineral/Coliform Bacteria (4391) F Dibromochloropropane (4392) 11 Arsenic (4393) <br />INTENDED USE Domestic/Private Irrigation/Agricultural r Industrial - Water Quality Monitoring KSoil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New Well i7 Replacement Well C Well Alteration/Modification = Other <br />Monitoring Well(s) # of wells Soil Boring(s) _ _ # of borings X Geotechnical # ofborings <br />Out -Of -Service Well - Out -Of -Service Well Renewal - Cross -Connection Repair <br />�u=uYauan <br />Drilling Method Mud Rotary n Air Rotary XAuger r Cable Tool -1 Push Point Other <br />Proposed Well Depth ft Excavation in diameter 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 Schad Steel L Plastic _i Stainless Steel 7 Other <br />Grout Seal Depth15_2= ft( Neat Cement (94 lb bag/5-10 gal water) F Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) Other <br />Grout Placement Method I Pumped i Free Fall Other I Retardant /Accelerator (name) <br />PEDESTAL Installed By i Driller Pump Contractor i Other <br />11 Concrete Pedestal nDimensions: Width ft Length ft Thick in i] Christy Box ❑ Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />1 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 />SIGNED <br />/ADEPARTMENT USE GNLY <br />Application Accepted By // "v Data ai * � <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By _ Date <br />Area 04 Employee ID# <br />E SPECIAL Well Permit <br />D WAIVER Received <br />Constructed Well Depth <br />ft <br /><�0ft_�-_�, <br />EHD 43-06 revised 4114118 <br />WELL /PUMP PERMIT <br />