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WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 20 953-7Q97 FOR INSPECTIONS EXPIRES 1 Y AR FROM DATE ISSUED <br /> JOBADDRESS v1�V+`UT �N� V2 vVIR'� VJj�� ..2��... ' CITY/ZIP .\J1 <br /> CROSS STREET (,�+�J�`0'-' I�)'� PN - PARCEL SIZE U�V-L/ND E PLICATION# <br /> OWNER NAME - 1 N L1.4 �8y PHONE (4 <br /> OWNER ADDRESS f' U - "' ""i:' IAV ! &Q_" CI ISTATEIZIP+ JM1Y) CvIio'i3 <br /> CONTRACTOR IJry��i /I�1 'n✓' PHONE �C, �L�--7 7L) <br /> CONTRACTOR ADDRESS CITv/STATE/L ('P IAIYLT <br /> Z <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/ST <br /> ATE/ZIP ? I( <br /> LICENSE Arc-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring ySoil Sampling/Characterization <br /> Public Water System <br /> I/rtilrerent 1—Owner- Wale,System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Moni(onng Well(s) #of wells Soil Bonngls) x of borings �OGectechmcal 4:)f borings <br /> Out-Of-Service Well 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 tC Auger Cable Tool Push Point Other <br /> Proposed Wolf Depth It Excavation_��in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> ?:,mg t, Conductor Casing in diameter / Conductor Casing Depth N <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 4_-Z " J) Neat Cement(94 It,ba915-10 gai water) Sand Cement sack mW7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(nameI <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width ft Length it Thick to Christy Box Stove Pipe <br /> PUMP_ Submersible Turbine Other HP Pump Set ft Standing Water Level ft� <br /> I HEREBY CERTIFY THAT 1 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 /> MINI UM�2((y�'(]yj�R ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 3-7 97 <br /> SIGNEDTITLE _AL' 1 �l ✓ <br /> i (Ar S� DATE 7 �( <br /> n <br /> o if C N Y <br /> ENVI - <br /> I E T L <br /> E T <br /> F E4 <br /> EPt T M E N T US tO L o <br /> Application Accepted By r Date �/ Area t Employee ID#I�S�� <br /> 9 If <br /> Grout Inspection By Date PECI Well Permit <br /> Pump Inspection By ' Date WAIVER Received <br /> Soil Boring InsEection By Date A Constructed W 11 Dept'P!' ft <br /> COMI�jNTS ,Y, <br /> 3a4 v <br /> PE SC Rec ived Check#/ Amount Permit/Codes Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> -� +10 -^ <br /> EHC 43-06 8,01,16 WELL'PUMP PERMIT <br />