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7 /Z i} 'etz-1 D y sir ' <br /> WELL/PUMP PERMIT <br /> SAN JOAQUICOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REF DABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �( N <br /> JOB ADDRESS �Oh illehaYoiAan1 V 0 Cm21P m <br /> D <br /> CROSS STREET - APN PARCEL P LAND USE APPLICATION# a <br /> m <br /> OWNER NAME S PHONE on <br /> OWNER ADDRESS,/ C CITY/STATE/ZIP <br /> CONTRACTOR ►t,1�`1t' rn1A 10`��L 1 PHONCf) OqI <br /> CONTRACTOR ADDRESS `[ ,I Aril._ A;rQ6Yf =1(,r4� CITYISTATE21P 'ter i <br /> SUBCONTRACTOR �1 n f� LPHOLNrE <br /> SUBCONTRACTOR ADDRESS 1L���n�E�PYEg���l/k CI7Y/STATE/LP 16(.f�tO <br /> LICENSE V"C 57 D C-61 L D-09 a Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring " oil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 0 New Well 7 Replacement Well 7 Well Alteration/Modification D Other ��� <br /> 0 Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings V9.-Otechnlcal ftofbodngs <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D Mud Rotary, C Air Rotary Vruger 0 Cable Tool r Push Point C Other <br /> Proposed Well Depth 5-1✓ ft Excavation in diameter I Open Bottom ❑Gravel Pack/Gravel Size in drmeter <br /> '7 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched j Steel i Plastic u Stainless Steel u Other <br /> Grout Seal Depth ft Meat Cement(94 Ib bag/5-10 gal water) 7 Sand Cement sack mW7 gal water <br /> i Bentonite(20%solids) i Other <br /> Grout Placement Method,/Pumped C Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller 0 Pump Contractor L Other <br /> n Concrete Pedestal nDimensions:Width ft Length ft Thick in - Christy Box - Stove Pipe <br /> PUMP D Submersible Turbine Other HP Pump Set 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 COMPENSATI N LAWS. <br /> MINIMUM 4 / DVANCE NOTICE REQUIRED FOR I/jVSrPECTiONS`-PLEASE CALL(209)953-7607 <br /> SIGNED TILE)r7 TY P'4 1YNr DATE / <br /> Nr <br /> 19 <br /> T <br /> ASR MENT U E O LY <br /> Application Accepted By to Area Employee ID#-r7 <br /> Grout Inspection By ate SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft t rq <br /> COMMENTS Li Aa n Det, o r Q,T. rake x 5* �J' -31 Ya/ 4� r'µ <br /> t- our 9� -4.f <br /> ,Iver {p y o ,,a l � m el,j pa-Ajp�r W Jj a 16 ' ltA 4-. V 4-k f►� 5,12-1111. <br /> PE SC Received Check#/ Amount Permit SGfr (�/IM1n.t�) <br /> Codes Info- .Cash emitted Date S rvice Request# invoice# Well ID# }+ <br /> , <br /> Z Ka V S <br /> EHD 43-06 revised 4/14118 WELL/PUMP PERMIT <br />