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j. V <br /> WELL/PUMP PERMIT 1 <br /> SAN JO..OUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE.STOCKTON CA 95205-(209)466-3420 <br /> SUED <br /> NON-REFUNDABL P R T CALL 209 5 7697 FOR INSPECTIONS EXPIRES 1 YEAR ROM ATE ISN <br /> /� c4n C a m <br /> JOB ADDRESS ` CI7YRJP D <br /> 0 <br /> GROSS STREET 1 }APNLq <br /> (� � PARCEL SIZE��.LAND USE AQPtJ{ATlON#� m <br /> V6 rb J...n.iI Gi'I L A Ji�'� PHONE L/••S G( <br /> ry ` OWNER NAME C p r` <br /> A t,V`ry 1t.lj ` f CITYISTAT..... ` `U <br /> OWNER ADDRESS � � � � " l <br /> \C,k` CONTRACTOR A PHONE t//ft �W <br /> CONTRACTOR ADDRESS 6 CITYfSTATflCff`ll 16` ` <br /> (SUBCONTRACTOR PHONE N <br /> ia <br /> SUBCONTRACTOR ADDRESS ('�zy1STATE21P 'r�i 1 1 <br /> IJCENSE C-57 G-61 D-09 Other NUMBER"% • (2XPIRAT1ON DATE <br /> DOMESTIC WELL PUNc_ General Minerai)Colifon-n Bacteria(4391) Dibromochicropropane(4392) Arsenic(4393) <br /> INTENDED use V DomesticJPrivate Imga:iordAgricultural Indusinai Water Duality Monitoring Soil SampBnglCheractenzation <br /> Public Water System <br /> li different from Owner. Ware,System Name Caniact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) C of wells Seil Borings) <br /> R df bongs Geotechnical_"or borings <br /> Out-Of-Servi W Out-Of-Service Well Renewal .Cross-Connection Repair <br /> _ New 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 eiameter Open Bottom Gravel Pack/Gravel Size it diameter <br /> Conductor Casing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel .Other r 1 <br /> Grout Seal Depth ft Neat Cement(94 fb bag/5-10 gal wafer) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant i Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_it Len th ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set It 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 ORD( ANC STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE IT HE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL V v <br /> WORKERS COMPENSA AWS. <br /> MINIMU UR ADV NCE NOTICE REQUIRED FQR INSPECTIONS-/L/PLEASE CALL(209)9 7� <br /> SIGNED TITLE U, e/ DATE <br /> I LL <br /> PAY�E� I W 11111• <br /> �C� 5 <br /> i <br /> S�NVIR�NP <br /> D AR MEN7 US O LY ��'1//u�,//�/ <br /> Application Accepted By ate Area--yL Employee ID*��1 ��"''' <br /> Grout lnspection By Date SPECIAL Well PerTnit <br /> Pump inspection By ,.\ i . De te WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC I Received he Amount Date PermrU Invoice# W.11 ID# <br /> codes Info B as emitted ServiceR uest# <br /> i u 3 `- <br /> I <br /> EHO 47.06 101116 WELL(PUMP PERWT <br />