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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDAB M C L 209 53 7697 FOR INSPECTIONS EXPIRES 1 YEAR FRgm DATE ISSUED <br /> !^l N <br /> Jos ADDRESS CITYIZJP -• m <br /> CROSS STREET I / o S m rd/ 6 AFN 3 O� PARCEL SIZE USE APPLICATION# <br /> VVVV/ lP0- !VS i w <br /> OWNER NAME (/ E <br /> OWNER ADDRESS �/'� C`�/]��"� M f` CIT(�11P <N <br /> �L l// J "`• 1 I �/ A/1 _ _ (PHONE ^r <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS CITY( TATEIZr7001 T-Lt;jL4 IP <br /> (SUBCONTRACTOR N- NPHONE <br /> SUBCONTRACTOR ADDRESS 6Y/ST.ATFJ7JP <br /> LICENSE C-57 C-61 D-09 Other NU BER IlY/l Ill••(lam^/y'� EXPIRATION DATE T' <br /> DOMESTIC WELLS PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private 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 q <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other \ <br /> #of borings #of borings <br /> Monitoring Wells) #of wells Soil Borings i Geotechnical <br /> Out-Of-Servic I Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pumpump Replacemen 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 It 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 mix17 gal water, <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> �1�• <br /> PEDESTAL Installed By Driller Pump Contractor Other \ <br /> oncrete Pedestal Dimensions:Width ft Len th ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Sel It Standing Water Level ft I1 <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 C <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HO VAN NOTICE REQUIRED FOR NSSP�E/C]TIIO(NNSlA-PLEASE CALL(209 9 FiT9X77 <br /> SIGNED TITLE DATE <br /> r 1 <br /> 11 7— <br /> VV <br /> CZ <br /> ?o O <br /> dog 19 <br /> I QMH <br /> J✓J, I P A T M t�1 .,� ��N[L L�Y ������ ����y�j M <br /> Application Accepted 8y Date_�f�C,T Area J//_'7 Employee ID#���j117.(Gr// FHT <br /> Grout Inspection By Date 1 SPECIAL Well Permit <br /> Pump Inspection By �0 DateV �� WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received hec Amount PerrniV <br /> Co s Info El ash emitted Date ervice Re nest# Invoice# Well ID# <br /> 0 50 <br /> EHO 43-06 B101/16 WELL/PUMP PERMIT <br />