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3AN 1 <br />SAN jut, <br />ENVIR <br />Hep' Tv <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDA L RMIT CA L 209 953-7 97 FOR INSPECTIONS EXPR S 1 YEAR Rom DATE ISSUED <br />JOe ADDRESS CITY/ZIP%j& It (4 7 <br />CROSS STREET�_��A/Pf�jIl, — �A(A/RCE�L SIZE USE APPLICfIT N #' <br />V r • I 14 V �%PONEs (01/ <br />OWNER NAME Q/ � /j <br />OWNER ADDRESS � � CITY/STATE/ZIP ki <br />G <br />lll'i�iyl!!//,tl � 4 <br />CONTRACTOR PHON <br />�) <br />-A <br />CONTRACTOR ADDRESS t T IgrA 1�/TJ <br />SUBCONTRACTOR PHO�4 l <br />SUBCONTRACTOR ADDRESS �CJTV/STATFJZIP <br />LICENSE C-57 C-61 D-09 Othe NUM 1/lL/]O EXPIRATION DATE <br />e� <br />)OMESTIC WELL $ PLING: General Mineral/GOIITorM b@CTena (4391) Dibrurnucnluruplupatic t+oac/ ..w t I <br />NTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If deferent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK New WBII Keplacement vveu vveu rnerauonnwwuu;auvn vas <br />z of borings A of borings <br />Monitoring Wells) # of wells Soil Boring(s) Geotechnical <br />Out -Of -Service Well Out-Of-Servtc . "'^ enewal Gross -Connection Repair <br />New Pump Pump Replacement Pump Repair Raise Well Casing ._. _ _ <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 It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth It Neat Cement (94 Ib bagl5-10 gal water) Sand Cement sack mixl7 gal water <br />N <br />A <br />N <br />ft <br />Bentonite <br />Bentonite (20% solids) Other <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) t~ <br />PEDESTAL Installed By Dnller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Length It Thick in Christy Box Stove Pipg <br />--it — <br />(PUMP _ Submersible Turbine_ _ Other HP Pump $e[ ft Standing Water Level `�1 ]�ft <br />I HEREBY CERTIFY THA <br />I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDI ANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE:' ITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSA - N LAWS. ^ <br />MINIMUM DVANCE NOTICE REQUIRED FOR IN ECTIIOnNSS-P�C( '4 <br />(209 <br />/f/I Y 3-7 7 <br />SIGNED TITLES" 1� ! / Y/1 ! ( ' //�DATE <br />A <br />�1:, <br />NT U E O LY <br />4%ffA <br />Application Accepted By <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Employee ID# D <br />PECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />/. PROMi7/l/bMF_r►l G I/1A1�►L1111i�►7T�ir�f�I�� <br />EHC43-06 6101/16 <br />WELL /PUMP PERMIT <br />i <br />�1 <br />