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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 E/XP!IRES�1 YEtAJR FROMDATEISSUED <br /> JOB ADDRESS L-W 9 L I CITY/ZIP St'V 1 �( �. 6WI :14AC7 m <br /> CROSS STREET t� �l'\V 1 i � h APN M— ( lJ 0- 14L")L1) PARCEL SIZE _LAND USE APPLICATION# O <br /> +, ami <br /> OWNER NAME �,L,��11rs} 9/�E Kf �`1 U PHONE <br /> OWNER ADDRESS ✓ \;'V I ul' tl �' 1 CITY/STATE/ZIPtI�'/I111/1 <br /> CONTRACTOR S ! I I \ V �1 '1I I� N j N� MPHONE <br /> /iA �] <br /> CONTRACTOR ADDRESS I V L/ '� _ CITY/STATE/ZIP I// �'1 ✓ �� / <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS i CI <br /> 1TY <br /> Y//S <br /> TA <br /> 1T <br /> �E/ZIP <br /> LICENSE t/C-57 I C-61 D-09 I I Other NUMBER \'!W L' '22— EXPIRATION DATE GIA 30 �I <br /> DOMESTIC WELL SAMPLING: General Mi eral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE 11 Domestic/Private 1 rrigation/Agricultural I I Industrial I I Water Quality Monitoring I I Soil Sampling/Charackrization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Numb T <br /> TYPE OF WORK I_ New Well I I Replacement Well L_I Well Alteration/Modification ❑ Other MD <br /> # pJ <br /> I_l Monitoring Wells) #of wells ❑ Soil Boring(s) of borings I� Geotechnical b rings(J 9 <br /> 1_1 Out-Of-Service Well ❑ Out-Of-Service Well Renewal 11 Cross-Connection Repair SqNJo'qQ(12019 <br /> I I New Pum !! Pum Replacement 11 Pump Repair I I Raise Well Casingf <br /> / <br /> WELL CONSTRUCTIONSTH pIV <br /> EP ENTqL <br /> Drilling Method S'Mud Rotary I I Air Rotary I I Auger I I Cable Tool U Push Point 1 Other gRTME <br /> Proposed Well Depth 410 <br /> ft Excavation _� in diameter fl Open Bottom /Gravel Pack/Gravel Size_ in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter /i in Thickness/Gauge/ASTM Sched li00 1 Steel /Plastic I I Stainless Steel l Other <br /> Grout Seal Depth__ft ❑ Neat Cement(94/b bag/5-10 gal water) '{�7 Sand Cement 10• sack mix/7 gal water <br /> Bentonite y20%solids) ❑ Other <br /> Grout Placement Method Pumped !J Free Fall ❑ Other I! Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller CI Pump Contractor rl Other <br /> L Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible I Turbine 11 Other HP Pump Set 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 /> MI I U 8 �ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9953-7697 <br /> SIGNED TITLE 1�A,w DATE L" - 1 <br /> Ilk <br /> r� <br /> V <br /> 1 <br /> U <br /> N <br /> ki <br /> o <br /> G� <br /> ArMENT SELY <br /> M <br /> Application Accepted By <br /> Date Area " Employee ID#� <br /> Grout Inspection By x ' _ '� Date , Q/zIV ❑ SPE dIAL W@II Permit <br /> Pump!nspection By Date 1 ; WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well IDft <br /> Codes Info y ash emitted Service Request# <br /> aY =L� <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />