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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-REFUNDA PE C ALL 209 953-7697 FOR INSP I EXPIRES�1�1I YE FFRO E ISSUED <br /> JOB ADDRESS 7 CITY P 'I r 19v N <br /> m <br /> CROSS STREET APN -I PARCEL S'ZE A"LAN.USE APPLICATION 9 o <br /> m <br /> OWNERNAMEPHON w <br /> OWNER ADDRESS J �� • L` U CITY/STATE/ZIP ( <br /> CONTRACTOR '� ,`)WL �/ P {NEE13, <br /> D ` f� <br /> CONTRACTOR ADDRESS V "� �� r CITY/ TAT ( / 5�150 v 1v 1 <br /> !SUBCONTRACTOR ! eP1tjE <br /> SUBCONTRACTOR ADDRESS ' r QITY/STATE/ZIP N <br /> LICENSE C-57 C-61 D-09 Othef NUMBERv'�l(PIRATION DAT <br /> DOMESTIC WELL SOPLING: General Mineral/Coliform Bacteria(4391 j Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE r Domestic/Private Irrigation/Agricultural Industnal Water Quality Monitoring Soil Sampling/Characterization h <br /> Public Water System <br /> If ddfe ent from Ow ec Nater System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> �- <br /> Monitoring Well(s) #of wells Soil Boring(s) it of boon9s #of borings Geotechnical i <br /> Out-Of-Service 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 Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 It,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 /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length R Thickin Christy Box Stove Pi e <br /> PUMP Submersible Turbine Other HP a Pump Set ft 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 <br /> JOAQUIN COUNTY ORDI IN S, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS v 1 <br /> CURRENT AND ACTIVE THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSA WS. <br /> MINIMUM R ADV E NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)9$3-7697 <br /> SIGNED TITLEf`�/� V r"`'� 04 Ot r) DATE�31Z <br /> i <br /> -'T <br /> YMENT' <br /> CEIVED <br /> 1 g 2019 <br /> QUIN COUNTY <br /> tj N7Y <br /> EPARTMENT <br /> I <br /> E P R T M ENT U E O L Y <br /> Application Accepted By , Date Area Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By � � � l L Date��hT(�� WAIVER ReCelVed <br /> Soil Bonng Inspection By Date Constructed Well Depth <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info emitted_ Dam Service Request# Invoice# Well ID# <br /> n <br /> I <br /> WELL/PUMPPERMIT <br />