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j <br /> WELL/PUMP PERMIT <br /> r SAN JOAQ IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� // yA0 ep `f I CITY/ZIP r f <br /> m <br /> ,RqCROSS STREET u APN `}q ��v PARCEL SIZE LAND USE APPLICATION# o <br /> OWNER NAME90YPHONE ��-L6 1 6 e� (n <br /> OWNER ADDRESS YY�r� / CITY/STATE/ZIP b I:LD <br /> CONTRACTOR f'�-[A>» LIZ PHONE <br /> CONTRACTOR ADDRESS A 13—&/ L-7� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST`AT�ncE/ZIP <br /> LICENSE X�-57 [I C-61 [:1 D-09 ❑Other NUMBER-� /�Uv EXPIRATION DATE V^ �� <br /> DOMESTIC WELL SAMPLING:R)General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name contact Name or Phone Number <br /> TYPE OF WORK y<New Well ❑Replacement Well [-]Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings #of borings <br /> []Geotechnical <br /> F]Out-Of-Service Well [-]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTIOON"" <br /> Drilling Methodr�llviud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth :�'_x ft Excavation in diameter ❑Open Bottom <Gravel Pack/Gravel Size in diameter <br /> ❑Conduc r Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in T ckness/Gauge/ASTM ScheclZ._00 E]Steel Plastic E]Stainless Steel E]Other <br /> Grout Seal Depth p � El Neat Cement(94/b bag/5-10 gal water) and Cement -& i,> sack mix17 gal water <br /> ❑Bentonite(20%s ds) ❑Other <br /> Grout Placement Method il<Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By iller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal Epimensions:Widthft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP A<SubmersibleElTurbine []Other HPC 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 /> MINI H R ADVANCE NOTICE REQUIRED FOR�IN"S�PECTIONS - PLEASE CALL (209)) 953-769)7 <br /> SIGNED ir. TITLE ©W DATE <br /> Q <br /> AJC <br /> ( V/ uouhrt <br /> Pq r <br /> F T. <br /> DE ARTMENT YSEJ ONLY <br /> t <br /> Application Accepted By % Date Area Employee ID#-� <br /> Grout Inspection Date ElSPECIAL Well Permit <br /> Pump Inspection By - Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth y 3 C) ft <br /> COMMENTS ktl4ff P z /L� �42tllJ/ � 7`0 AAjT�q ooy —44 lJ[T <br /> 9tA44 — <br /> PE Sc Received h Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> ?-5-1-7 1. 6 -1 1 k,/ c7 . 67 9 1 <br /> EHD 43-06 8/01116 <br />