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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•bTOCKTON CA 95206-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 2091 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> nn_�7,�, (,I}--2 ISM,�r�2J CInl21v ' + <br /> JOBADDRESS G jrbr C,7'N Y/L 07 4, (F R..�iNT Li r�r<p �/,f/�`�,/ lir 5I <br /> n / D <br /> CROSS STREET,�Ir 7 F C r Y�u�S'� APN-Z CLQ"`(3�'000 PARCEL SIZE 7!?'L LAND USE APPLICATION# <br /> /� <br /> OWNER NAME A 1C �. JI,IAV ft/(��1,P f/>-T/�/C' 5 rPHONE <br /> OWNER ADDRESS t}Ili CP"117 r'�S V N�.I`/ - I t JJ'1 CITY/STATEMP l�('('yI o /Al',��,'r,T2�j 4 (� <br /> CONTRACTOR \AJktV-1 ISS.VI-II.- i kC'C 1 4-T S PHONE Ell b "13 LA <br /> CONTRACTOR ADDRESS /V !�I�y�CITK,t�- n�I(U'J CITY/STATE/ZIP �^%�TS� SI•VG11•-"\Wl 10CA70'1 i <br /> SUBCONTRACTOR til G !L 1 N 'I PHONE '�C17, <br /> SUBCONTRACTOR ADDRESS "I�j� �/ U <br /> CITY/STAT <br /> E/ZIP ffiWLTAA/ �N qq�5- <br /> LICENSE C-57 I'. C-61 I D-09 i Other NUMBER I(�1 LILI/� EXPIRATIONDATE VI b Li/I <br /> DoMEsnc WELL SAMPLING: 1 General Mineral/Coliform Bacteria(4391)I Dibromochloropropane(4392)I Arsenic(4393) <br /> INTENDED USE 1 Domestic/Private _i Irrigation/Agricultural r Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 1 New Well _I Replacement Well f Well Alteration/Modification I Other <br /> Monitoring Well(s) #of wells oil Boring(s) #'Ofbodngs `>�Geotechnical _A of borings <br /> i Out-Of-Service Well vut-Of-Service Well Renewal ;Cross-Connection Repair <br /> l New Pump Pump Replacement L Pump Repair L Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _I Mud Rotary 1 Air Rotary Auger�1F.1 Cable Tool 1 Push Point 1 Othe <br /> ` r <br /> Proposed Well Depth I�"c J ft Excavation t_in diameter C Open Bottom 7 Gravel Pack/Gravel Size in diameter <br /> 7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad I Steel I Plastic I Stainless Steel i Other <br /> Grout Seal Depth 1, Vin?' ft yNeat Cement(94 lb bag/5-10 gal water) I Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method r Pumped i Free Fall Other 1 fM I v i Retardant 1 Accelerator(name) <br /> PEDESTAL Installed By j Driller i Pump Contractor Other <br /> 7 Concrete Pedestal I Dimensions:Width it Length ft Thick In I Christy Box i Stove Pipe <br /> PUMP .1 Submersible_-i Turbine I: Other HP Pump Sel ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> MI/NiIMUM 48 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 53- 69? <br /> SIGNED :.._1 0� - TITLE CLAD J EL'-f V-r/.�/I,C�1(S� DATE <br /> r <br /> to <br /> COU <br /> 4',NY <br /> � <br /> T <br /> DEPARTMENT US ONLY <br /> Application Accepted By !✓ Date 5 20 Area 5 i Employee ID#_� t1 <br /> Grout Inspection By A LA <br /> Date I 9PECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection B Date Constructed Well Depth ft <br /> COMMENTS ie� ry frc� <br /> —ZZZ= T S !Y�al-(�ta�-Q y U TIno y- 9�j <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info emitted ice Request# <br /> f J11 <br /> EHD 43-08 revised 4/14118 WELL/PUMP PERMIT <br />