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WELL/PUMP PERMIT <br /> SAN JOAOtm COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT AL 09 90-207 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CIrrIZIP <br /> /. a <br /> CROSS STREET 1`l. APN Oq • .3 PARCEL SIZE,1 v r LAND USE APPLICATIO # o <br /> `, 7 Y in <br /> � <br /> OWNER NAME �:°v1 L' 1 �LHONE� '�^T / r)� l I rya. <br /> OWNER ADDRESS' �`1.C:(ir l u V e' CITY/STATFJZIP f� <br /> CONTRACTOR (�, V(�-, ` by\ I1 1A PHONE CZt •��';]&777b <br /> � <br /> CONTRACTOR ADDRESS t._AAJ''J - ,44 V- CITY/STATEMP P'1V,_ebl L r\IL,jC44 <br /> SUBCONTRACTOR 1� I PHONE <br /> SUBCONTRACTOR ADDRESS C.IITY/STATE/ZIP <br /> G 1 ,�. <br /> + 1 <br /> LICENSE C-57 C-61 D-09 Other NUMBER 1 3 EXPIRATION DATE ` .� l <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(4391)LDibromochloropropane(4392)C.Arsenic(4393) <br /> INTENDED USE Xomestic/Private n Irrigation/Agricultural ❑Industrial Water Quality Monitoring I I Soil Sampling/Characterization <br /> Public Water System <br /> If diferent from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK )<New Well 7 Replacement Well r Well A@eration/Modification Li Other <br /> Monitoring Wail(s) #of wells 0 Soil Boring(s) 9 of borings n Geotechnical tl of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal -_Cross-Connection Repair <br /> New Pum i Pump Replacement 'i Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'y,Mud Rotary L Air Rotary Auger -Cable Tool . Push Point L Other <br /> Proposed Well Depth ft Excavation J11 in diameter _Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Condu or Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad Steel Plastic C:Stainless Steel Other <br /> Grout Seal Depth It =Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> )!(Bentonite(20%solids) D Other <br /> Grout Placement Method umped G Free Fall LJ Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -Pump Contractor El Other <br /> Concrete Pedestal (Dimensions:Width ft Length it Thick in Christy Box Stove Pipe <br /> PUMP Submersible_Turbine 1.j Other HP 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 ANDATHAT 1 AM IN COMPLIANCE WITH ALL 4 <br /> WORKERS COMPENSATION LAWS. rrF /I/ Airs, <br /> R ii.E G7ic� REQIlt12ED FOR tAdS'?� 'It <br /> CG^✓a5—PLEASE CALL(209)953-7697 <br /> SIGNED TITLE I �I DATE <br /> RQ�iNC 8 <br /> H p pMEIyr�fY <br /> ,gRTM��T <br /> Jill <br /> AR MENT U E .S� <br /> Application Accepted By ate Area-t �� Employee ID# r+"' <br /> Grout Inspection By Date I 1 SPECIAL WBII Permit <br /> Pump Inspection By Dale / Q WAIVER Received <br /> Soil Boring io By ,Daae Constructed Well Depth ft <br /> COMMENTSM0 L V Y' <br /> PE SC Received ChecW Amount to PermiU Invoice# Well ID# <br /> Codes I a Remitted Service R uest# <br /> EH0 43-06 mmsed 4/14/18 WELL[PUMP PERMr <br />