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I^ <br /> WELL/PUMP PERMIT D <br /> u <br /> SAN JOAOUIN COUNTY ENVIRO MENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-$TOCKTON CA 95205 (209}4ti <br /> y <br /> NON-REFUNDA LE PERMIT';, C 209 953- IONS EXPIRES 1 YEAR FRo TE ISSUED <br /> G y <br /> • JOB ADDRESS ZzSI, L� CITY roc a m <br /> L�t �J�j� u wtwFer a O�CX✓ ✓M <br /> CROSS STREET M Ina r10,• APN ( . W`� PARCEL SRE LAND 1J APPLICATION# of <br /> p <br /> OWNER NAME - <br /> ONE <br /> OWNER ADDRESS iaff a/� CITY TA El P <br /> CONTRACT( `�� i��� <br /> NTRACTORADDRESS v __ _ A IP <br /> SUBCONTRACTOR _. l PHONE, <br /> SUBCONTRACTOR ADDRESS CI7yIST/]A�TE�P N ` 1 ?o-2 <br /> C-61 J <br /> LICENSE C-57 D-09 Other B k ^// EXPIRATION DAT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Ome.0 lPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owmec Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Sal Boring(s) a of borings Geotechnical If of oonngs (1� <br /> Out-Of-Service W Out-Of-Service Well Renewal - Cross-Connection Repair <br /> _ New Pump ump 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 It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel .Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ancrete Pedestal Dimensions:Width ft Length ft Thi k in Christy Box Stove P' e <br /> PUMP V Submersible Turbine Other HP Pump Set ft Standing Water Leve 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 /> WORKS SATION LAWS. <br /> .......... <br /> NIM 24 HOUR T INSPECTIONS-PLEASE CALL(20 5 - 9 <br /> SIGNEDTITLE xv nQ DATE <br /> CTq t _ <br /> AV <br /> l4 <br /> //1 <br /> RECE9V <br /> O D PaR T Date U S 1 O N Y Area��SPE! <br /> Employee ID# <br /> ',1 a C;ot D estlon Accepted By (y/AI//_I {� <br /> SAN J RON Grout Inspection By Date ell Permit <br /> ENutRpNMENTA� <br /> HEAUTN <br /> pEpARTM �p Inspection By �cQdOXI �lL�� 1A Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Permit/ <br /> Date Invoice# Well ID# <br /> Codes Info By ash 7 Remitted Service R uest#e <br /> ZZ 72 V — <br /> I <br /> EH043-06 VOtne WELL(PUMP PERMIT <br />