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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAZELTON AVENUE-STOCKTON CA 9$205-(209)466.3420 <br /> NON-REF NDA LE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �.� �.--y �7 y <br /> Joe AD E s ov �a c��� Cm/ZIP DU. --e <br /> ( 'A <br /> �{a— '/1 � D <br /> CROSS STREET NW Ct)I \{� (9i�r S'�UAPN „1)'l-N.]O' _3�PARCEL SIZE X_V ANDD APPLICATION# a <br /> OWNER NAME \ r=• - MrGV$G !/r�D—ZS�SC1—/(�D,,� H <br /> AJAIF <br /> TAT <br /> OWNER ADDRESS - /V. e6S;!TE/ZIP /'tpHy�'I'�1t•Y,A Ii/I/OG-q� q <br /> CONTRACTOR � / 14 J41 PHONE(209) 7 C- r' 7^_)126 <br /> CONTRACTOR ADDRESS 'r /IUP Cml$TATE/ZIP_ C7r^19 )L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS Cm77II�SS��TATE/ZIP 1-30 <br /> T <br /> LICENSE pc C-57 C-61 D-09 Other NUMBER - LC/l EXPIRATION DATE / 30 - w4.G <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesticiPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Xoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Watw Syaiam.Nam- Comacd Nam-or Phew Numb-r <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification OtherQ Z <br /> Monitoring Well(s) #of wells Soil Boring(s) x df bonn9s )(Geotechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair LU 0 LL <br /> New Pump Pump Replacement Pump Repair Raise Well Casing p S SC <br /> WELL CONSTRUCTION > CV <br /> Drilling Method Mud Rotary Air Rotary (Auger Cable Tool Push Point Other W>� C' j Z LL <br /> Proposed� Depth��it Excavation 1sr/ in diameter Open Bottom Gravel Pack/Gravel Size in diameter M � W <br /> %!)n r I rly Conductor Casing in diameter / Conductor Casing Depth It U Z <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other ■ ■ O ix <br /> Grout Seal Depth it }Neat Cement(94 1b bag/5-10 gal water) Sand Cement sack mW7 gal water ���W/// a <br /> Bentonite(20%solids) Other <br /> Grout Placement Method)Pumped Free Fall Other Retardant/Accelerator(name) s� LU <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set R Standing Water Level h <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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953�-77697 <br /> SIGNED TITLE f c1AFd4rDATE "'lL",ZO/75 <br /> ✓4 F/L <br /> TSR�iN 0 FA <br /> A 111. <br /> �O�g <br /> h�FayRFN gLN�1- <br /> MF'�'T <br /> PA/R�TMENT USE Y <br /> Application Accepted By �CCeGI Date�% Area Employee'/ Employee ID# 1 <br /> Grout Inspection By Date P_ECIAA-L Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Dale7/1'/,� Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Checkl4 Amount DatePermiU Invoice# Well 1O# <br /> Codes Info Cash a tte a 'e e N <br /> EHO43-06 m—d4/1411871Q�/./ -�j- WELL(PUMP PERMIT <br />