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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-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> -34()Ig �ze h t 9�Joe ADDRESS � <br /> CROSS STREET S 4 0C t^ `y APN U 15'�I -150 PARCEL SIZE L LAND VladAVMU1CATIO(N s (J/'� S <br /> OWNER NAME `A - U r e PHONE`/—\1U' ,1`y— l�,/7� -I0 u <br /> OWNER ADDRESS �-1 1Cc1�{'r �. CITYISTATErble �V l.st�/�'n1 U` 1 .7CAA 9 <br /> CONTRACTOR �ak- hIT r`t\ /� 1 PHONE1��`n 1 �(y�C• 1z�] <br /> CONTRACTOR ADDRESS��C f']��X q� CITY/STATEMP C—, CA+ C A 1 JC^/ a <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS 'CfrY/STAATEEZP 1 �]' <br /> LICENSE 1,C-57 JC C-61 _:D-09 - Other NUMBER �( IL�-J07 EXPIRATON DATE J1 `-' <br /> DOMESTIC WELL SAMPLING: General MineraUColiform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE +i Domest cfPhvate Irrigation/Agricultural - Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> Ir different from Owner Water System Name Contad Name or Phone Number <br /> TYPE OF WORK 75 New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells -Soil Boring(s) #of bonoga - Geotechnical #of beings <br /> Out-Of-Service Well Out-Of-Service Well Renewal -Cross-Connection Repair <br /> Xn-c Pur-"pi _- -------- r^-wTi I---WELL CONSTRUCTION <br /> CONSTRUCTION <br /> Drilling Method SCMud Rotary C Air Rotary Auger Cable Tool -'Push Point - Other <br /> Proposed Wall Depth `x.�C'� R Excavation in diameter -Open Bottom >:Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter 1 Conductor Casing Depth ft <br /> Well Casing Diameter C% in Thickness/Gauge/ASTM Schad Steel IK Plastic Stainless Steel _ Other <br /> Grout Seal Depth I7 ft D Neat Cement(94 Ib bag/5-10pal water) ;F`Sand Cement )Cr sack mIx17 gal water <br /> Benlonite(20%solids) C Other <br /> f:r...f Pl!rnmun}rJNhC!A t'P,'Mpt'd Free Fa!! Otho, - Pnlerd!!nf I Acr--!ti!tr Inamc) <br /> PEDESTAL Installed By y, Dnller ^_Pump Contractor Other <br /> L Concrete Pedestal Dimensions:Width R Length R Thick in .Christy Box Stow Pipe <br /> �PuMP Submersible Turbine - Other HP Pump Set R Standing Water Level Imo'_• R <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED � � // c,ll't t7 TITLE �I 't f_ f)rCS t C{C'r DATE I C t tV <br /> r <br /> PA TMEIN U E` N L Y <br /> Application Accepted By a Area Employee ID# <br /> Grout Inspection By i Dete $PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Dete Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permits <br /> Codes Info Cash Remitted Date Service Request# Invoice# Well ID# <br /> A62 Aev—,Ey 0 (r 91I <br /> nL L i <br /> a (% <br /> EHD43-06 r--d 4A4119 /�/l��q^j j'� WELL A'UMP PERMIT <br />