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t , <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZFLTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 95t3--7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 13 CI SC, L i b e c- /-j ��J ✓ 'J/ CfTYZP C' �. C1S\C/ J <br /> -T' APN foto � Z2'1 ly & gD <br /> CROs STREET .1 rL�\,�-� �� '�C �n / PARCEL SIZE AND UsE ACPPLICATION`#/� Q g <br /> OWNER NAME V C C 1 C — PHONE <br /> H/ONE��5)�n -L!to (-�1�1�L35 kpiwi <br /> OWNER ADORESS •`4 /I/�L�/L� CrTY/STATEIZIP �C Y✓f'(�(/V ` -a L <br /> CONTRACTOR i L' '�r Y � � ) t�Ll PHONE / n / <br /> CONTRACTOR ADDRESS 1' l 4 CITY/STATEZPA <br /> _rel l 1\ �'`S l✓5 <br /> SUBCONTRACTOR PHONi <br /> SUBCONTRACTOR ADDRESS CITY/STATEZP �7 7/1 <br /> LICENSE �C-57 -C-61 _D-09 Other NUMBER LL 5` 7 /ExPIRATION DATE -3� <br /> DOMEsnc WELLSAMPUNG:_:General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)'._Arsenic(4393) PA <br /> INTENDED USE /,Domestic/Private Irrigation/Agricultural :.;Industrial Water Quality Monitoring -Soil Sampling/Characterization �� <br /> -Public Water System <br /> If different ham Owner: Water System Name Canted Name or Phone Number <br /> TYPE OF WORK /,(,New Well C Replacement Well -1 Well Alteration/Modification .-Other �� <br /> I A/ <br /> Monitoring Wells) It of wells _ Soil BOnng(S) s of borings Geotechnical a of bonne, <br /> -.Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair SAS JO 209 <br /> X New Pum Pu Replacement Pum Repair Raise Well Cacin p� <br /> WELL CONSTRUCTION N /,` t✓OvA, <br /> Drilling Method�Mud Rotary Air Rotary --Auger -Cable Tool Push Point - Other �ACTf-/ G +Y/l r- F�T,QC''YY'r <br /> Proposed Well Depth ��tC: it Excavation _in diameter :I Open Bottom /.Gravel Pack/Gravel Size )/A in diameter RTMFNT <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C-�in Thickness/Gauge/ASTM Sched (-))1­L -Steel p4 Plastic L Stainless Steel .Other <br /> Grout Seal Depth `IL'C' tt -Neat Cement(941b bag/5-10 gal water) 7C Sand Cement 1(,' S sack mtxn 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 SDlmenslons:Width ft Length j it Thick in Christy Box .Stove Plpe <br /> PUMP ,Submersible'..--Turbine :- Other HP / Pump Set aC'L) ft Standing Water Level l C. 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 /> WORKERS COMPENSATION LAWS. <br /> 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASECALL(209)953-7697 <br /> SIGNED G�fi.A./J-�v TITLE \1 1 e P:-C's f� 'n 1 DATE <br /> M ,\ <br /> 7-1 <br /> FEE] J <br /> FTTT <br /> C <br /> r <br /> P' TM ENT U E O LY <br /> Application Accepted By toArea Employee ID#- Y-t-+-z-" <br /> Grout Inspection By Date s PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> i <br /> Soil Boring Inspection By Date —7, Construct II Depth - i I� ft <br /> COMMENTSi �'�/tiE9 ^� <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Ifo Cash Remitted Service R uest# <br /> AM el- 1 wh <br /> k/1 Ll <br /> r- <br /> EHD 43-06 ravlsed 4!14118 �373F 7S� WELL/PUMP PERMIT <br />