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10 <br /> 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 209953-7697 FOR <br /> -(INSPE TIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 29-150 W. es Yd• ` U L- CIN/zIP 6 CA 9 S(03 2 y <br /> J �7 <br /> CROSS STREET _AP N OOI I IOD/ PARCEL SIZE I31-39LAND USE APPLICATION 4 p <br /> OWNER NAME r��(]IIO �1,t�1 eV`A.1r�,�� InC• PHONNE,�L2��-3/�-1�'1)"- (D Zoo N <br /> OWNER ADDRESS J-!�� 1y —t1J V�jE't r CITY/STATEIZIP �V InQdMn Cr\ `1533`) <br /> CONTRACTOR t-j,(, �1 PIi {bt"p PHO 209-rto32r-3N1^ <br /> CONTRACTOR ADDRESS )P)csx X0375 CITY/STATE/ZIP BAson Cfl 953 219 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIrYISTATE/ZIIP <br /> LICENSE NUMBERL[� EXPIRATION DATE 314 <br /> _-- <br /> 1( <br /> DOMESTIC WELL SAMPLING: Genera(Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE 2 Domestic/Private Irrigation/Agricultural G Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> Public Water System <br /> Irdifrerent from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well F Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells ❑Soil Boring(s) a of borings ❑Geotechnical n of bonngs <br /> XOut-Of-Service Well W 3 17 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pum D Pump Replacement ❑Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method '�Mud Rotary ❑Air Rotary D Auger n Cable Tool C Push Point n Other <br /> Proposed Well Depth if Excavation in diameter n Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> -1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched D Steel D Plastic ❑Stainless Steel D Other <br /> Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> F Bentonite(20%solids) ❑Other <br /> Grout Placement Method F Pumped D Free Fall G Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller D Pump Contractor ❑ Other <br /> F Concrete Pedestal DDlmensions:Width it Length ft Thick in n Christy Box D Stove Pipe <br /> PUMP n Submersible❑Turbine ❑Other HP Pump Sel ft Standing Water Level ft <br /> 1 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 /> MINIMU UR ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76977 <br /> SIGNED TITLE Wee6r GVI-CV DATE 1/ 1201"Q <br /> SI <br /> !� <br /> - E9��Ro4 c0 <br /> T�/OFpgR��� <br /> DEPARTMENT USE ONLY <br /> �� C 'yf / C c1 Ahmed <br /> Application Accepted By �M / W� Data I J I Area r Employee ID# <br /> Grout Inspection By Date 17 SPECIAL Well Permit <br /> Pump Inspection By Dale ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth fl <br /> COMMENTS 'V�`�- <br /> PE SC Received Chec Amount Date Permitl Invoice# Well ID# <br /> Codes Info B IT Remitt d Service Request# <br /> 175101 <br /> EH04106 8MI116 WELL(PUMP PERMIT <br />