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WELL/PUMP PERMIT <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDAB PERMIT C 209 53-769 FO INSPECTIONS EXPIR S 1 YE ROM 7 SSUED <br /> _ ca o h <br /> JOB ADDRESS CITYZP <br /> I `J CROSS STREET III Arj gv�-a?/0-0/ PARCEL SIZEOLANDU P TION -� y p <br /> in III <br /> OWNER NAME 'n tx,. /� PHONE ,n <br /> OWNERADDRESS (J' V I A,fit la CITY/$TATEZP O� G 1 N� <br /> CONTRACTOR f�VI'✓ ✓ \�PHH/O�ONNNE ! <br /> CONTRACTOR ADDRESS V • W Y CT'ISTATE/ZIP `� _ _ <br /> SUBCONTRACTOR rtlNE I ILII <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Olh Zl NUMBER-✓ ( V EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General erallColiform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Indusinal Water Quality Monitoring Soil SempiinglCharacterization <br /> Public Water System <br /> n different from Owner Wale,System Name Conlact Name m Ph°ne Number <br /> TYPE OF WORK Now Well Replacement Well Well AlterationlModification Other <br /> Monitoring Well(s) >:of wells Soil Boring(s) "Of bw gs Geotechnical <br /> 1Jut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> V New <br /> Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schell Steel Plastic Stainless Steel Other m <br /> Grout Seal Depth it Neat Cement(94 lb bag15-10 gal water) Sand Cement sack mix17 gal water to. <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor OtherC <br /> oncrate Pedestal Dimensions:Width m it L n it Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water LevelJAW- <br /> ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 9 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE I$ <br /> CURRE ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WO RSC .PENSATION LAWS�VANj��E <br /> ("1 <br /> U 24 HOU UIRE FO�TIONS-PLEASE CALL(209)953-7697 <br /> SIGNED T LE tAW C ,4j DATE W <br /> IFN <br /> oec <br /> 1U� � <br /> S ��NM�NM"TRTMENT U E ON Y <br /> T}i pEPcation Accepted By (ltitpl - — Date 2 Q Area Employee ID# <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Permit/ <br /> Inf Ca emitted Date c...,:..n R uesl# Invoice# Well ION <br /> EHD 4346 6101115 WELL iPUMP PERMIT <br />