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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 E PERMIT 209 954-297 97 FOR INSPECTIONS EXPIR S 1 YEAR ROM DATE ISSUED <br /> �] (/ Lo <br /> JOB ADDRESS CITY/ZIP �' • C `� m <br /> CROSS STREET APN g-a 30 Q/ PARCEL SIZE USE APPLw/T#i— - r r p <br /> etea - LSU In <br /> OWNER NAME �/ // r' O E 1/J 41 <br /> OWNER ADDRESS <br /> /}. U `tet t+k � IC <br /> CFfIcArYTY/STA E ZIP v V/' <br /> CONTRACTOR J i'r ��/I�� �(L PHQNE �/ <br /> CONTRACTOR ADDRE '" ✓I`� / `�tTW / I <br /> SUBCONTRACTOR PIJONE <br /> SUBCONTRACTOR ADORES 1'/STATEIZIIPn N L131 I 7 ,4 <br /> LICENSE C-57 C-61 D-09 Othe NUMB V 1�/0 EXPIRATION DA V Q <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 /> PubliPublic Water System <br /> I/ <br /> c <br /> from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> tt of borings <br /> Monitoring Wells) #of wells Soil Boring(S) Geotechnical #of borings <br /> Out-Of-Service WOut-Of-Service Well Renewal gross-Connection Repair <br /> New Pump Pump 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 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 Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth It Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water Cb <br /> Bentonite(20%solids) Other <—N <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) C1 <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 V Submersible Turbine Other HP Pump Set ft Standing Water Leve <br /> I HEREBY CERT' <br /> THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ^, <br /> JOAQUIN COON ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS v 1 <br /> CURRENTAND IVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS CODA SATION LAWS. <br /> MINI M UR ADVANCE NOTICE REQUIRED FOR IFY ` <br /> NS CN ARSE CALL(209)9 3-7697 <br /> SIGNED TITLE utn co I DATE <br /> IN <br /> R gYMF <br /> Novo? O <br /> I . <br /> J�Q <br /> Rp <br /> wit-,1-77 <br /> NT <br /> AZENT USE ONLYApplication Accepted By "/t�(. ate��� Area 'yam/'/I /_ Employee ID#_�� <br /> Grout Inspection By ,A Date SPECIASL Well Permit 77 " <br /> Pump Inspection By <br /> Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Che Amount PermiU <br /> Codes Info B ash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43.06 &OV16 WELL(PUMP PERMIT <br />