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r Lf <br /> ' 4 <br /> WELL/PUMP PERMIT <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDAM PERMIT 12 <br /> }�/C�1/A��L/L',22009 9 3-7 97 FOR INSPECTIONS EXPIRES 1 YAR FR D T ISSUED <br /> 9101 <br /> JOB ADDRESS V� o• r/ (.L!f 1 CITY "D Cat L 0 Llm <br /> CROSS STREET APN 7�l l PARCEL SIZEArAND US PLICATION# <br /> ro <br /> OWNER NAME �,//�� PH�cONNyE�,� - (� vi <br /> OWNER ADDRESS 1 b I 0,1-1 "' 1 CITU/ST E/ IP �� • <br /> CONTRACTOR �G PHO E <br /> CONTRACTOR ADDRESS Cj C!71.c G l CITYISTATE I <br /> SUBCONTRACTOR )yr <br /> PHONE <br /> SUBCONTRACTOR ADDRESS [ / CITY/STATE/ZIP/��tl <br /> LICENSE C-57 ✓ C-61 D-09 Othe�� NUMBER 2,3 `✓&Y/QXPIRATION DATE <br /> DOMESTIC WELLS PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization rO <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 Wells) #of wells Soil Boring #of borings #of boringss) Geotechnical �. <br /> Out-Of-Service W�11 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum \/Pum 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 / 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 bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other T <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PAYME IIIIESTAL Installed By Driller Pump Contractor Other (1 <br /> oncrete Pedestal Dimensions:Width ft Len th ft Thick in Christy Box Stove P' a �1 <br /> RECE <br /> uMP V Submersible Turbine Other HP Pump Set ft Standing Water Level <br /> BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IN E IS <br /> MAY o a URRENT AND N ACTIVE TY (WITH THE SCAL CALIFORNIA CONTRACTORS TATE LAWS, AND RULES NSTATE U LICENSE BOARD AND LATIONS. I ALSO CERTIFY <br /> HAT I AM IN COMPLIANCE IW TH ALL <br /> COMPENSATION LAWS. /��� <br /> SpN JI4RONN MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR�TIONSn-P E 1 CALL(209)9 -7697 <br /> ENVIRONMENTPJ- �/ l� <br /> HEA)-TM DEPAI�4NT TITLE DATE 1� <br /> V_ <br /> PA TMENT U /E// N�Y <br /> Application Accepted By Date� Area_� Employee ID# <br /> Grout Inspection By Date SPECIAL WeII Permit <br /> Pump Inspection By 0, Date WAIVER Received <br /> Soil Boring Inspection By Date v Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date PermlU Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> G' <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />