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y WELL/PUMP PERMITy' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205•(209)!iw <br /> NON-REFUNDABL PERMIT CALL 20 953-7697 FOR INSPECTIONS PI EXPIRES 1 YAR FROM DATE ISSUED <br /> ' rn <br /> .JOB ADDRESS CITY/7J ( I <br /> m <br /> D <br /> CROSS STREET A5 3 <br /> PN i �I PARCEL SIZ f LAND USE APPLICATION ii A <br /> rem, w <br /> OWNER NAME � 1/P � PHONE('--�y/-�� <br /> OWNER ADORE • V CITY/STATE/ZIP 1 <br /> CONTRACTOR I Q 1� �—�+ • *TYISTE <br /> {� (qH�A/NE / yt�r�CONTRACTOR ADD 5 �—° P � "" ✓ <br /> `^1 <br /> SUBCONTRACTOR PHQN� pp���i <br /> SUBCONTRACTOR ADDRESyISTATE/ZIP TR <br /> 17��/ 110,` <br /> LICENSE C-57 V C-61 D-09 Othe_1 NUMBER EXPIRATION DAT 3 l V <br /> DOMESTIC WEL!S—G PLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE v Domestic/Private Irrigation/Agricultural Industrial Water quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> It afferent from Owner. water System Name Contact Name or Phone Number <br /> I <br /> TYPE OF WORK New Well Replacement Well Well Aheration,Mobifeation Other <br /> Monitoring Well(s) #of wells Soil Bonrg(s 1 sof borings Geotechnical <br /> Out-Of-Service Out-Of-Service Well Renewal Gross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter i Conductor Casing Depth ft <br /> Well Casing Diameter_:n Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water � <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ncrete Pedestal Dimensions:Width ft Len th it Thick in Christy Box Stove Pipe <br /> PUMP Suomersible Turbine Other HP Pump Set I U V 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 li <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 /> M 24 HO DV CE N TICE RE [RED FORiNS/P1�ECTI/ �/ <br /> O�NSt/-PLEASE <br /> CALL(209)Gr]m�3 7697 -� <br /> SIGNECMI i `� I lJt- I Y I Y I DAT J -N4--- <br /> I <br /> I i <br /> � I I <br /> i <br /> I <br /> vJ F <br /> PAYM <br /> �ECEI i I � I <br /> G I I <br /> I <br /> JUN � 3 <br /> JOAaUIN CONN E= R T M E N'__ E10I -C�`t -y— <br /> $� Accepted B Area Cate � Employee ID# <br /> HEALTH pEpART NM Etat — — <br /> �rct Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By — ,��k \ Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Weil Depth It <br /> PE SC Received h Amount Date PeranN Invoice# Well ID# <br /> Codes Info B Cash emittee Service Re Request# <br /> 2 131 <br /> i <br /> � i I <br /> _. - WELL tPUMP PERMIT <br />