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WELL/PUMP PERMIT <br /> SAN JOAOUIN 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 /> JOB ADDRESS lT) N <br /> m <br /> ICROSs STREEr I_TIA Wim, APN '-O PARCELSIZE3"f- D USE APPLICATION# p <br /> OWNER NAMEl—=i4 (\�--' ( ��/�f—tin\IIA 1, PHONE <br /> OWNER ADDRESS �J -( �')� /1� �J CITY/STATEILP <br /> CONTRACTOR jj 1 'c I O o I / C �, PHONE�o o� ,�, Cf� <br /> CONTRACTOR ADDRESS 1 tI ` ` � I- CmISTATEMP KIT/`4/`N14ee ��,?-"jr' I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrrY/STATEMP <br /> LICENSE -C-57 -C-61 D-09 r.-Other a� NUMBER ) ' T ExPIRAncN DATE <br /> DOMEsnc WELL SAMPLING:,_General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)L Arsenic(4393) <br /> INTENDED USE u-Domestic/Private Irrigation/Agricultural D Industrial C Water Quality Monitoring a Soil Sampling/Characterization <br /> Public Water System <br /> if different from Ovmer: water System Name Contact Name or Phone Number <br /> TYPE OF WORK _New Well t.;Replacement Well ❑Well Alteration/Modification i Other <br /> MonitoringWell(s) #of wells 0 Soil Boring(s) uofborings Geotechnical #ofbod.gs <br /> Put-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair C��a-�•'ii� <br /> 'New Pump C Pump Replacement ❑Pump Repair _l Raise Well Casing <br /> WELL CONSTRUCTION /r <br /> Drilling Method I Mud Rotary i Air Rotary i Auger i- Cable Tool 1 Push Point Il Other <br /> Proposed Well Depth it Excavation in diameter Ci Open Bottom Li Gravel Pack/Gravel Size g `049 <br /> Conductor Casing in diameter / Conductor Casing Depth it y IN C <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad T-,Steel ❑Plastic F1 Stainless Steel ❑Other MFNTVN�y <br /> Grout Seal Depth ft fi Neat Cement(94 lb bagJS-f0 gal water) n g <br /> Sand Cement sack mfxl7 gal wate RTMdi <br /> Bentonite(20%solids) -I Other _ NT <br /> Grout Placement Method Ll Pumped -Free Fall L Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ')l Driller I Pump Contractor r Other <br /> Concrete Pedestal _Dimensions:Width it Length itThick in u Christy Box L Stove Pipe <br /> PUMP i Submersible-Turbine ❑Other HP Z� Pump Set 1!t It 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 /> at /' fv 'g NOs r t7Vi':NCE NOTICE=REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9p3-711)97. <br /> SIGNED N i \_ TITLE F/ �i/ /��>y✓ DATE !;),T_/ <br /> '1 <br /> n <br /> 1 <br /> AR MENT U�Y /��/�/T <br /> Application Accepted By ate � � Area�(� Employee ID#J`��/PIW <br /> Grout Inspection By Date ❑ PECIAL Well Permit <br /> Pump Inspection By t !'S vtT� 4`tiA% , Date y �'� C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received he Amount Date Pertnd/ Invoice# Well 10# <br /> Codes Info By_ ash Remitted ce Request# <br /> 1021 41-52- <br /> 2M2/ <br /> EHD43-15 revise14/14i78 a�c /t WELL[PUMP PERMIT <br />