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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-U97 F R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS C CITY/ZIP ��/tom/✓U m <br /> CROSS STREETC���✓riti - /�`j�/�r'ePjN �' �y I PARCEL SIZE _LAND USE APPLICATION# <br /> OWNER NAME J ? ! /1' ��/e PHONE ( !C - ' U? <br /> OWNER ADDRESS �� �-� CITY/STATE/ZIP <br /> CONTRACTOR l�~'\ � �+ /.E��� Y PHONE 7 0' <br /> J e7" <br /> CONTRACTOR ADDRESSr�L •�� CITY/STATE/ZIP <br /> SUBCONTRACTOR ,l�1 <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STAT�EI/'ZIP /� <br /> LICENSE Jt',;�-57 C-61 I7 D-09 Other NUMBER �yA7� EXPIRATION DATE - rf <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I i Irrigation/Agricultural LI Industrial 11 Water Quality Monitoring L 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 I Replacement Well I I Well Alteration/Modification ❑ Other <br /> Monitoring Well(s) #of wells I Soil Boring(s) #of borings ❑ Geotechnical of borings <br /> Out-Of-Service Well I I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ?r-Uew Pump I I Pump Replacement I I Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r2$Aud Rotary ❑ Air Rotary LI Auger LI Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth L c�' ft Excavation ['L in diameter I I Open Bottom IXravel Pack/Gravel Size in diameter <br /> i-i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 16L in Thickness/Gauge/ASTM SchedI I Steel �yplastic LI Stainless Steel,, 11 Other <br /> A <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Ll Sand Cement �y��sack mix17 al water <br /> (I Bentonite(20%solids) ❑ Other 5 PAYMENT <br /> Grout Placement Method FL Pumped ❑ Free Fall Other I! Retardant/Accelerator(name) <br /> PEDESTAL Installed By .Driller ❑ Pump Contract o i I Other <br /> Concrete Pedestal ❑Dimensions:Width ft Length ,> ft Thick n Christy Box to i 1 <br /> PUMP --Submersible❑ Turbine ❑ Other HP .J Pump Set ft Standing Wat6AN\L*AQUIN COUftl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCO T <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RE <br /> MIM <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 O/UJft ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 9/53-776[97 <br /> SIGNED / ` TITLES��e'« L/ DATE <br /> o d'KWONG PWDWU d',Daly Ad Tops Time le Em onmem Heaeh De... PP G"It Maps jdf Wong EEHf.0,,o .. d Pa—I Ve HEALTH EHO d Pe R PIus}erfwonglwl0... 2 Business Pons1 Sign In d CEFS C-2012 F-2195 d ftba. <br /> Perereeer <br /> hrd ID - <br /> Flots <br /> tt f I Gw1wl <br /> i - 13 oslxlu1'r y'.w .0001,M1111 <br /> 1--to <br /> -� - TYPe sauc <br /> - WEea elewm <br /> ;�i c.w------........... <br /> E:'I e..ol mase <br /> , x t P I I� ! '-� � <br /> — p ! El a i t <br /> r 2 ii t,Ii i (f l !! fi I _. <br /> _ �l;,:tEIE(YcE F Ef,i1ti.:�t.I, <br /> ieH <br /> -- earEr,Ie i <br /> WTO <br /> G � i <br /> .- —_ _ _ t7JwnoPeasu► <br /> ertpT ] <br /> ttc:� <br /> r�! Eeauem <br /> suo 6a01®WIIIQ: Nnv �Rc 0.,.vc =w o... orHgt5R6..(� yu s •., s •+1 -. __ _ - nar..r...a.r...� <br /> (Exesa..alnEtaea - v! <br /> Mal Phop 201E May lR �- <br /> mne-- _. ___._ v.slw.rEt arc.vy..v �r:t>.aemn s,<x•c 2lbfI.szs <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> EHD4�-C' 8101/16 WELL/PUMP PERMIT <br />