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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 PCERRMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1J <br /> Joe ADDRESS \ I Q , CRYMP PIS, <br /> CROSS STREET I..cJ.'l Q, \d�LL \1p APN f� PARCEL SIZE LAND USE APPLICATION o <br /> \ t� <br /> OWNER NAME J�KVZ.. SC'v3�AYr' PHONE bC;' 1 l�\6 <br /> c V 7 <br /> OWNER ADDRESS ) 7IOO` 24LI l�:.H� CITY/STATE/ZIP c-Ac,'�`'�1, <br /> CONTRACTOR Ry,It INrG(1 EA,-3c,, <br /> ,{�✓�i PHONE tri LA <br /> CONTRACTOR ADDRESS �.(,L-C) L—�x..Jc,r A,, T'FV1• Cr1Y/STATE/LP E!;c.:- CA <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/LP <br /> LICENSE y G-57 n C-61 n D-09 ^i Other NUMBER�ct CJ E%PIRATION DATE <br /> DoMEsT1C WELL SAMPLING:n General MineraUColiform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE )(DomesticJPrivate a Irrigation/Agricultural a Industrial U Water Quality Monitoring u Soil Sampling/Characterization <br /> n Public Water System <br /> If dnw d Iron Owner: Wale,System Name C.*A d Name m Phone N-", Ade <br /> TYPE OF WORK a New Well a Replacement Well a Well Alteration/Modfication u Otter N x <br /> n Monitoring Weil(s) #of wells n Sal Boring(s) a of towngs n Geotechnical #of bwngs <br /> u Out-Of-Service Well a Out-Of-Service Well Renewal a Cross-Connection Repair <br /> New Pump n Pump Replacement n Pump Repair n Raise Well Casing �® <br /> WELL CONSTRUCTION O <br /> Drilling Method n Mud Rotary n Air Rotary n Auger n Cable Tool n Push Point n Other I) 019 <br /> Proposed Well Depth ft Excavation in diameter n Open Bottom n Gravel Pack/Gravel Size i Q11) <br /> (/� <br /> F!Conductor Casing in diameter / Conductor Casing Depth It T OHq' 0j j <br /> Schad Well Casing Diameter_in Thickness/Gauge/ASTM Sad n Steel n n Plastic Stainless Steel n Other FP RHT rC'V7)' <br /> Grout Seal Depth ft n Neat Cement(94 Ib beg/5-10 gal water) n Sand Cement sack mixll gal water TMF <br /> F1 Bentonite(20%solids) n Other NT <br /> Grout Placement Method n Pumped n Free Fail n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By Li Driller ump Contractor w' Other <br /> Concrete Pedestal F,Dimensions:Width it Length ft Thick in n Christy Box n Stove Pipe <br /> Pu P XSubmersible a Turbine U Other____RA HP Pump Set 1�-O ft Standing Water Level CDG 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIIM�M��UyyMJ�48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLEIy Y,�.L DATE ,IN <br /> L. w e" <br /> IV <br /> N, <br /> 9 — — <br /> tiI 9�' <br /> G <br /> f3 <br /> d <br /> DJFP RTMENT S ONLY <br /> Application Accepted By Dat Area Employee ID# <br /> Grout Inspection By Date *USPEIL We11 Permit <br /> Pump Inspection By imwvv� Date;Nj n. WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Cha Amount Date Permd/ Invoice# Well ID# <br /> Codes Info ash Remitted ervice R ue t# <br /> L <br /> EHD 43-08 m~4/14/18 WELL/PUMP PERMIT <br />