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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-REF N LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRE s ts1 f eSc�t4ero Flvrnc,r, CITY2In Tr^r/ 95?�oti( In <br /> CROSS STREET gorrt, M._A tl,�r APN 2 13-D7D- Qy IIZI bD <br /> [ ! EL SIZE .7�-•�f�l LAND USE APPLICATION# v <br /> OWNER NAME 01 ct G-I 0-ILS LLC, PHONE <br /> OWNERADDRESS `` 1-r-;&r WODCJ JtrC -r <br /> CONTRACTOR V KW C)'• K V1(inA l PHONE �9 �n I - 7756 <br /> CONTRACTOR ADDRESS II33 QI4"C )-'6, Dr"VPi CrTY/STATE21P GIT/ c A / 95632 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C-n/Y/$TATErZip <br /> LICENSE C-57 n C•61 ❑0-09 n Other NUMBER !2 O 9 0 I EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE ❑DomestcfPrlvate n Irrigation/Agricultural ❑Industrial n Water Quality Monitoring n Soil Sampling/Characterization <br /> n Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK f7 New Well ❑Replacement Well n Well Alteration/Mo ' tion n Other <br /> n Monitoring Well(s) #of wells X Soil Borings) #of borings n Geotechnical #of borings <br /> F1 Out-Of-Service Well n Out-Of-Service Well Renewal n Cross-Connection Repair <br /> F New Pump ❑Pump Replacement 11 Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method n Mud Rotary n Air Rotary YAuger n Cable Tool n Push Point n Other o�v <br /> Proposed Well Depth 10-1 a/ ft Excavation in diameter n Open Bottom n Gravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad n Steel n Plastic ❑Stainless Steel n Other <br /> Grout Seal Depth 10-2Sr ft XNeat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> FI Bentonite(20%solids) n Other <br /> Grout Placement Method X Pumped n Free Fall n Other n Retardant/ elerator(nam <br /> PEDESTAL Installed By n Driller n Pump Contractor n Other <br /> FI Concrete Pedestal nDlmensions:Width ft Le ft Thick i [I Christy Box 11 Stove Pipe <br /> PUMP n Submersiblen Turbine n Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS AP LI ATI D AT TFFFFFF������666666-��-WORK BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND L D REVU T 1 ALSO RTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA COT CTO STATE LI E E OARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI M 48 OUR ANCE NOTICE Q N PECTIONS-PLEASE CALL(209)953-7697 Q <br /> SIGNED DATE 1/4 1 <br /> ENT <br /> 6VED <br /> 4 2099 <br /> IN COUNTY <br /> MENTAL <br /> PARTMENT <br /> D PA MENT U�Y '�� ��� <br /> Application Accepted By ate Areae►���f�Q(�( Employee ID#y�y������ <br /> Grout Inspection By Date ❑ SPECIAL 811 Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed We11 pth {-` , ��A <br /> v Loo <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B ash emitted Date Servlee uest# Invoice# WeIIID# <br /> EHD 43-06 revised 4/14118 WELL/PUMP PERMIT <br />