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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 2Q9)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> p� � to <br /> Jos ADDRESS -1 C, AV CITY/ZIP N))o, 0 <br /> 7 D <br /> CRG33 STREET D�A.,P�N�dq a —ryin J I IRCEL SIZE LAND USE APPLICATION <br /> OWNERNAMEs�/�////�/GiWPHONE �7 N <br /> OWNER AODRE33 �TA It /,{/�/� CITY/$TATEIZIP <br /> CONTRACTOR r�1 /7 PHONE /,/ 2dl � <br /> CONTRACTOR ADDRESS " CITY/STATE/ZIP 1(IJLk "-/S J <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZJP <br /> LICENSE t,C-57 ..i C-61 ❑D-09 n Other NUMBER3744" EXPIRATION DATE <br /> DOMESTIC WELL SAMPUNG::J General Mineral/Coliform Bacteria(4391)fl Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE DOmes(ic/Prlvale U Irrigation/Agricultural U Industrial n Water Quality Monitoring 0 Soil Sampling/Characterization <br /> Public Water System <br /> Ir dHerenl Isom Ovmer. Wale,Syalem Name C-tacl Nanta or Phone Nuntbe, <br /> TYPE OF WORK n New Well n Replacement Well n Well Alteration/Modieralion n Other <br /> 'I Monitoring Wells) #of wells 0 Soll Bodng(s) 0 of bodngs a Geotechnical 9 of borings <br /> i I Out-Of-Service Well u Out-Of-Service Well Renewal a Cross-Connection Repair <br /> eNew Pump n Pump Replacement 0 Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTIO <br /> Drilling Method a Mud Rotary U Air Rotary U Auger u Cable Tool U Push Point u Other <br /> Proposed Well Depth fl Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> .I Conductor Casing in diameter / Conductor Casing Depth H <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth fl 0 Neat Cement(94 lb bag/5-10 gal water) U Sand Cement sack mixl7 gel water <br /> 1 Bentonite(20%solids) n Other <br /> Grout Placement Method t--Pumped n Free Fall n Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller ump Contractor n Other <br /> n Concrete Pedestal UDhnensions:Width�_It Length it Thick in n Christy Box n Stove Pipe <br /> PUMP XSubmersiblen Turbine o Other HP Pump Sel ft Standing Water Level ft <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 /> IN I UM 48 URADV NCE NOTICE REQUIRED F R NSPE^CfTIO C�PL(E S�Er CALL(209913-76q7 <br /> SIGNE s TITLE All (�. JJ l 1-(I�Jt DATE Z- <br /> lo <br /> W® o <br /> S ?019 <br /> Q(�j�CO <br /> -- pq�MEH <br /> T <br /> PA TMENT U E N L Y <br /> Application Accepted By Date 3� 99 AreaEmployee ID#,��� <br /> Grout Inspection By Date ��(� L SPECIAL Wall Permit <br /> Pump Inspection By �� t{ Dale ick_\ fl WAIVER Received <br /> Sall Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info 113YA gash Remitted 5 1 e R e t# <br /> EH04348 Fevised4n4118 F 77 Z WELL/PUMP PERMIT <br />