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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-$4�f <br /> NON REFUNDABL P MI CAL 209 953-7 97 FOR INSPECTIONS P (SES 1 Y FROM DATE I S <br /> ,JOB ADDRESS U _ Le <br /> CITYIZIP _" m <br /> 7 yy- D <br /> CROSS STREET , APN ZD • D PARCEL SIZE LAND USF'APPLt�ON III p <br /> {/rl{/ m <br /> n n Pbin <br /> PI+DNE <br /> OWNER NAME <br /> OWNER ADDRESS 6 crr�P 4� <br /> CONTRACTOP, I 's / PN <br /> CONTRACTOR ADOR�\E/SSS V CI ITAT <br /> tr <br /> SUBCONTRACTOR/y fFIt7NE <br /> SUaCONTRACTOR ADDRESS C /STATEMP <br /> LICENSE :-57 C-61 D-09 Other. NUMB (0(a O EXPIRATION DA <br /> DOMESTIC WEL(S�PLINK: General Mineral/Coliform Bacteria(4391) Olbromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE V Domestic/Pdvate Irrigation/Agricultiral Industrial Water quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> I+mllerent from Owner. Water System Name Contact Name or Phone Number i <br /> TYPE OF WORK NewWell Replacement Well Well AheratiorAiotlifcaticn Other <br /> F <br /> Monitoring'Nell(s) 0ofwells SoilBoncg�sl aof oormos Geotechnical of,tangs i <br /> ice <br /> WELL CONSfRUCnO Well Out-Of-Service well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Casing <br /> i C <br /> Drilling Method Mud ry Air Rotary Auger Cable Tbol push Point Other <br /> Proposed Well Depth It Excavation in dlar.e:er Open Bottom Gravel Pack/Gravel Size In dlameterl <br /> Conductor Casing in diameter ; Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bagi5-10 gal nater) Sand Cement sack mrx/7 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 /> Concrete Pedestal Dimensions:Width f• Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP - Pump Set, • ft Standing Water Level:=ft 1 <br /> I HEREBY CERTIFY THAT 1 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 1� <br /> CURRENT A ACTIVE WITH TH�AN�TICE <br /> LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL Iv ` <br /> WO S COMP SATION LAWS <br /> M 1 M 24 HOU REQUIRED FQft INSF(ECTIONS-PLEAS CALL(2033-76 7 !vv <br /> SIGNED TITLE O`'L , DATEMM L� <br /> ! i <br /> 1 <br /> I I <br /> I <br /> i <br /> 1 I <br /> ii y <br /> 2201 <br /> ! i v R Wu/ <br /> 71 %O .�° <br /> -- i H�Fpy Fir�N�Y <br /> `« D A R T M E SE O iijc <br /> Y <br /> Application Accepted By Cate (/V- l Area f Employee 09 <br /> Grout Inspection BUrl A&Date 1 SPECIAL We61 Permit <br /> Pump Inspection By VIAY Date WAIVER Received <br /> Soil Boring Inspection By_ Date Constructed Well Depth__ ft <br /> :JR1h1E^: <br /> PE SC Received I (2LckV Amount <br /> Permit/odeIfoDate <br /> Remittedst Invoice# Well ID# <br /> , Service Re I1 <br /> qo�s- <br /> --_ -,° - WELL.PUMPPERMIT <br />