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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468Qk�j <br /> NON-REFUNDAB PERMIT ALL 209 95 69 oR INS IONS'— EXPIR 1 YE o D I USD <br /> JOB ADDRESS V �t CITYlZP <br /> CROSS STREET � PNf _• �V PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME •r�• — UW PH/ <br /> OWNER ADDRE / �_C�. rn J--� CITY/STATE21P <br /> CONTRACTOR ' J"���LL �' • •ps r VV PHONFj� <br /> CONTRACTOR AD DR 5 �"•• CITY/ TATE/ <br /> SUBCONTRACTOR PHONE 11V I, Q <br /> SUBCONTRACTOR ADDRESSy ' C�J,TY/STATE21P <br /> LICENSE C-67 V C-61 D-09 Other NUM '(I� EXPIRATION DATE <br /> DOMESTIC WELL PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) V <br /> INTENDED USE V Domestic/Pdvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil 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 /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Servige dell Out-Of-Service Well Renewal Cross-Connection Repair <br /> _ New Pump V/ Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION `}v <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other _1 <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter S <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 bao-10 gal 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 /> Concrete Pedestal Dimensions:Width ft LeFjhj ft Thick in Christy Box Stove Pipe <br /> PUMP Submersib Tu *ne Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THA I E PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY OR ES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACT THE H THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN I LAWS. <br /> MINIMU HOUR ADV NOTICE REQUIRED FOS INSPE TIONS-PLEASE CALL(20 -76 7 / <br /> SIGNED TITLE DATE C -AV �Z^ <br /> V�(1 <br /> 7r 4�1 <br /> V`► <br /> EE-*#--- <br /> PA TMENT USE O L <br /> Application Accepted By Date Area 4 Employee ID# <br /> Grout Inspection By Date ECIAL Well Permit <br /> Pump Inspection By Date 7;U 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit) <br /> Cods Info B Cash emitted Date g rvice Request# Invoice# Well ID# <br /> 00,;q �3 <br /> EMD 43.06 6101/16 WELL/PUMP PERMIT <br />