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J. <br />3 <br />PA <br />JUN <br />SAN JOA <br />ENVIF <br />HEALTH <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTji DEPARTMENT 1868 EAST <br />NON-REFUNDABLE PERMIT%' C LLA(2q9)953-7697 FOR INSPECTU <br />JOB ADDRESS U v I I n 7, CITY/Zip <br />CROSS STREET , -1 / 9 w PARCEL SIZE <br />OWNER NAME A G 1' <br />OWNER ADDRESS 7 V V <br />CONTRACTOR `�--,T�I�'1 <br />CONTRACTOR ADDRESS i f/1� <br />SUBCONTRACTOR I <br />SUBCONTRACTOR ADDRESS <br />LICENSE C-57 C-61 D-09 <br />APN <br />AVENUE - STocKTON CA 95205 - (209) 468-3420 <br />EXPIRES 1 YEAR FROM DATE <br />rug <br />ISSUED <br />2LAN0 USE//t/�PPLI4ATION # <br />_ MONE /t 6 ` <br />�G 'T <br />Sr/_ a I) <br />PHONE <br />EXPIRATION <br />IOMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />1TENDED UsE Domestic/Private -Irrigation/Agricultural Industrial Water Quality Monitoring , <br />z SU <br />NUMBER v W&( <br />- Sail 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 Replacement Well _ Well Alteration/Modification Other <br />MonitoringWell(s) #of wells SoilBoring(s) #afborings Geotechnical riofborings <br />Out -Of -Serviced Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pum Replacement Pum Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary -Auger Cable Tool 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 Sched Steel Plastic _Stainless Steel -Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gat water) :Sand Cement sack mix/7 gal water <br />Bentonite (20% solids) -Other <br />Grout Placement Method Pumped Free Fall -Other Retardant /Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />oncrete Pedestal -Dimensions: Width ft Leng It Thick in a Christy Box _Stove Pipe <br />PUMP Submersible Turbine -Other HP Pump Set ft Standing Water Level ft <br />1 HEREBY CERTIFY THIA I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY OR AN S, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND AC' THE CALIF NIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENS <br />I AWS. <br />MINIMUM UR ANCE NOTICE REQUIRED FOR�(JS/P�E1CT^IOrNS -PLEA CALL (209)`�g5 -�$7 <br />SIGNED TITLEA� DATE � ` <br />y <br />m <br />g <br />A <br />w <br />-p TMENT U NLY <br />Application Accepted By Date Employee ID# <br />Area_<<�/'' <br />Grout Inspection By Date f SE PECIAL Well P@rITTIt <br />Pump Inspection By � WAIVER Received <br />Date,a����}{(� <br />Soil Boring Inspect <br />1 Z <br />�:1 �riL�:�l,//.�J <br />_ _ • � <br />L"Ti�1��C'►�:�►►l'1����5'iVA,�� <br />^C <br />Z <br />Date <br />Constructed Well Depth , ft <br />a= <br />Z <br />n <br />� = <br />co <br />C� <br />EHD 43-O6 8/0111 <br />�:1 �riL�:�l,//.�J <br />_ _ • � <br />L"Ti�1��C'►�:�►►l'1����5'iVA,�� <br />ion By <br />Date <br />Constructed Well Depth , ft <br />COMMENTS <br />EHD 43-O6 8/0111 <br />�:1 �riL�:�l,//.�J <br />_ _ • � <br />L"Ti�1��C'►�:�►►l'1����5'iVA,�� <br />6 <br />WELL /PUMP PERMIT <br />