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f� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 468.3420 <br />NON-REFUNDABLE PERMIT CALL 20 953-7697 FOR INSPECTIONS LEXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3550 -439Y = Worms St• CITY/ZIP <br />.,c <br />CROSS STREET �R'4rr,., w St. APN %0l7 " 3Z4 L� lI PARCEL SIZE 1 N �7 LAND USE/!APPLICATION # <br />OWNERNAME I nn Gt,//�Y.%I%.Z,�lN.,t)y�iJy-I�pJ�yTS[��/�17KO/.��6c). <�PHONE `20116`0 6393 <br />OWNER ADDRESS 7`D � y/ l l�. /�J`oo ��/V /i t-/Vr CITY/S <br />/ // T <br />OUTAAeTOR— Sb4nr7on k W lSc-n yhc— PHONE (91G),t 23D0 <br />GOUTRACTOR-ADDAT35 1/F22 3r�S�- S (OC% CITY/STATE/ZIP �'rLcarr�n lL/r�rl fj 1 <br />SUBCONTRACTOR 14 QGY- Dir ll7 PHONE <br />SUBCONTRACTOR ADDRESS �� "1v-es-t.Drt i (' t. CIIITYISTATE(ZIP <br />LICENSE I'C-57 C-61 = D-09 Other NUMBER "1 6992 EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Uactena (4391) - Dibromochloropropane (4392) C Arsenic (4393) <br />INTENDED USE - Domestic/Private _-. Inigation/Agricultural -: Industrial —Water Ouality Monitoring _ Soil Sampling/Characterization <br />u Public Water System <br />Vdifferent from Omer: Water System Name Contact Name or Phone Number <br />TYPE OF WORK C New Well - Replacement Well ❑ Well Alteration/Modification Other <br />G Monitonng Well(s) # of wells C Soil Bonng(s) M ofbodnga v Geotechnical A of boring, <br />D Out -Of -Service Well D Out -Of -Service Well Renewal :- Cross -Connection Repair <br />naise vven <br />Drilling Method YMud Rotary _, Air Rotary /Auger C Cable Tool - Push Point _ Other <br />Proposed Well Depth 4 5 ft Excavation F" in diameter - Open Boltom - Gravel Pack/Gravel Size in diameter <br />- Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thicknesrs/Gauge/ASTM Silted - Steel _ Plastic _ Stainless Steel = Other <br />Grout Seal Depth ft Y Neat Cement (94 /b bag/5-10 gal wafer) = Sand Cement sack mixfl gal water <br />Bentonite (20% solids) /..:`Other <br />Grout Placement Method C Pumped C. Free Fell &!Other Tlc. e. O Retardant / Accelerator (name) <br />PEDESTAL Installed By n Driller ❑ Pump Contractor -. Other <br />Concrete Pedestal CDimensions: Width ft Length ft Thick in - Christy Box Stove Pipe <br />PURIP =: Submersible.: Turbine - Other 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. 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 />MI M 48 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />VP / F'znlnra rine Cnnrriinm... _ ou n� int u <br />W <br />IN <br />V\ <br />DE RT ENT US O <br />Application Accepted By ' Dale — ` Area Employee ID#jW <br />Grout Inspection By Date J SPECIAL Well Permit <br />Pump Inspection By A.4 DateWAIVER Received <br />v <br />Soil BoringInsoe`et`Ion B ,l I Diate L Constructed Well Depth ft <br />COMMENTSrlC I I \ALL I 4 ul X� p <br />PE SC Received <br />Codes Info <br />Check#/ Amount Date Permit! Invoice # Well ID# <br />jRemltted rvice Re ueSt# <br />`Cash <br />k. "1 7 C7 <br />Eh047-06 revised 4114116 WELL/ PUMP PERMIT <br />