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(� WELUPUMP PERMIT <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1$68 EAST HAZELTON AVENUE y$TOCKTON CA 95205-(2D8i)�48 KEYED <br /> J NON-REFUNDABLE PERMIT`1 f /CALL 009)9553-7697 FOR INSPECTIONS EXPIRES 1 Y AIR FRO DA7 IIJJ <br /> ,JOB ADDRESS VA/I l/ "`//1 CI•ry(]Jp ll CO y <br /> a D <br /> CROSS STREETDo Ci �' Y�O PARCEL SIZE�I.MIQ.Nr li'q� # ' w <br /> j OWNER NAME e // /� /VV.�/VDj W <br /> OWNER ADDRESS `�G `^/�/r • CI/ AT IP (04" <br /> CONTRACTOR Q� PHON S ' e/,I� <br /> I CONTRACTOR ADDRE S ! � - /Zip _Q / <br /> !SUBCONTRACTOR PHONE �. <br /> SUBCONTRACTOR ADDRESS OUP <br /> LICENSE C-57 C-61 �D-09 Othe NU2 ` EXPIRATION DATE D <br /> 1 171 <br /> t1 <br /> DOMESTIC WELLS Y <br /> PILING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AlterationiModification Other <br /> Monitoring Well(s) #of wells Soil Bonng(s) 9o borings Geotechnical Sof borings <br /> Out-Of-Service W/ary Out-Of-Service Well Renewal Cross-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 / 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 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/Accelerator(name) <br /> I PEDESTAL Installed By Driller Pump Contractor Other <br /> C ncrete Pedestal Dimensions:Width it Length ft Thick in .Christy Box Stove Pipe <br /> PUMP VSubmersible Turbine Other HP Pump Se ft Standing Water Lev 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 n <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL v 1 <br /> WORKE$S-QAp(IPENSATION LA S. <br /> M I `UM 24 H A CE NOTICE REQUIRED FO NSPECTIONS-PLEASE CALL(209 -769 1 G ,� <br /> SIGNED T LE I - r�rn ra 1r 1 DATE <br /> ' FC <br /> 14 <br /> Npy <br /> D A TMEN SE OLY /� <br /> Application Accepted By %� Dale Area_�5b ^�_ Employee <br /> Grout Inspection By Date �10 WAIVER <br /> Well Permit i <br /> Pump Inspection ByDEW off"ODale WAIVER Received <br /> Soil Boring Inspection By Date Constructed Weil Depth ft <br /> COMMENTS \Nt . �.J�JO 1J�wYln t\M 't 4_, <br /> PE I SC I Received eck#/ Amount Permit/ <br /> d Info B emitted Date Service Reauest <br /> # invoice# Well ID# <br /> I <br /> EtiD 43-06 4,'01116 <br /> WELL/PUMP PERMIT <br />