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-7--!701 w . ( (+'A sr. <br /> r <br /> WELL/PUMP PERMIT NE l RESERVO I(� <br /> SAN JOAQUICIDABI-1 <br /> NTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTO VENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REF PERMIT CALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS NEAR 1322 N CHRISMN R^�jOA�D'''[ CITY2IP Tf�CY g590H m <br /> CROSS STREET CAR MEW <br /> AN E'7''�Q QAPNN/25 0-03D- D j' PARCEL SIZE%.62L„ND USE APPLICATIONN## <br /> OWNER NAME CIT'?t \ OF I FAC <br /> IG YPHONE IWIR <br /> OWNER ADDRESS 325ONCe4TE9 pLAZ4 CITY/STATEZPj�2n`VCA U4q5J' 3V^�I (p <br /> CONTRACTOR VJK A <br /> T w <br /> 5;50,C'A�S n LAE- <br /> ga5-315-3151 <br /> CONTRACTOR ADDRESS 399 LIt4I)Ej6ZGH Alfr=4 LIE CITYISTATEZP L%Ve li[ORE^jCA 184Q551 <br /> SUBCONTRACTOR TABe Rr�D ILL IOG `'�t PHONE C11(- r/7��� 1- 9/23 �/ 1 <br /> SUBCONTRACTOR ADDRESS53(0 GRUE-STO&I V-172661 CITyISTATEZP AL'5Ae &k46 1-0 CA I 1 I <br /> LICENSE C-57 Cft D-09 Other NUMBER gbffl 2a EXPIRATION DATE Z 129 �O20 <br /> DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring h Soil Sampling/Characterization <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 Well(s) #of wells X Soil Boring(s) 3 #of borings XGeotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum _:.Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary I Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depths -I S 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 <br /> inn (Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth-erf r 1 \ ft XNeat Cement(94/b bag/5-f0 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(207%s—olids) Other <br /> Grout Placement Method Pumped Free Fall Other GM E Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal .Dimensions:Width It Length 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 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 <br /> WORKERS COMPENSATION LAWS. <br /> MINI 8 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASECALL(209)953-7697 <br /> SIGNED TITLE-DG�1 DATE �� 1 <br /> R gyMF <br /> o0-FcF��NT <br /> F46 <br /> ogQU ?Q18 <br /> p RFT 941, �Y <br /> MFNT <br /> fiAR M ENT U E 04 LY <br /> Application Accepted By Area mployee ID# <br /> Grout Inspection By Date PECIAL W II Permit <br /> Pump Inspection By Date tt WAIVER Received <br /> Soil Boring Inspection By Date l I Constructed Well Depth ft <br /> COMMENTS / r-� <br /> r- c- f'l <br /> PE Sc Received he Amount Permit/ <br /> odes Inf as I Remitted oo Date Service Re ue t# Invoice# Well ID# <br /> EHD 43-06 revised 4114118 WELL/PUMP PERMIT <br />