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WELL/PUMP PERMIT <br /> SAN JOAOU!N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT .1850 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT _ wnvvv.sjgov.orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> M,-_ � m <br /> JOB ADDRESS/ CITYILA <br /> P f'- <br /> C� �J J� D <br /> CROSS STREET APN l9- =( ARCELSIZE C S '-LANo USE el- <br /> APPPP�LIICCAL}TION#/ 7p7 0 <br /> OWNER NAME � //-}�/] cPHO�NE�// !//moi(-441' (J L �J m <br /> OWNER ADDRESS _/�Oy (�j ,�Ly(/C CITYISTATE/ZIP_ <br /> CONTRACTOR ,/!�/L��JG�I)�/�/ /,�/� —/�(0/�'- 7� PHONE <br /> CONTRACTOR ADDRESS ;; /Z�J/9q.�l�(��� ^ G'/r' �� ^r- CITYISTATEIZIP � � 4" <br /> ,SUBCONTRACTOR/CONSULTANT //�/(-7G LL-[S Q���l�b _ PHONE <br /> SUBCONTRACTORICONSULTTAANT ADDRESS CITYISTATEIZIP <br /> LICENSE tlA-57 2rt-61 Cl D-09 ❑Other NUMBER EXPIRATION DATE_ <br /> BILLING PARTY: / 0 OWNER D CONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:r]General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) ip II-AI <br /> INTENDED USE_ DomestidPrlvale 0 IrrigalionlAgrlcullural ❑Industrial ❑Water Quailly Monitoring 0 Soil SamplinglCharacleriza L�j.�y�A� <br /> n Public Water System Gds <br /> Ir different from Owner. Weer Syelem Nem. Conl.cl Name or Phone Nwnber l <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well Allerallon/Modification 0 Other <br /> 0 Monitoring Wells) #ofwells O Soll Borings) #ofbor1no' 0 Geotechnical - -- ""NOUNC / <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair Ht� ROA1 O(JIV <br /> D New Pum 0 Pum Replacement 0 Pump Repair 0 Raise Well Casing TH DEpAR A( <br /> WELL CONSTRUCTION <br /> Drilling Method VMud Rotary D Air Rotary D Auger 0 Cable Tool O Push Point 0 Other <br /> / r <br /> Proposed Well Oepth /U It Excavation�2 / In diameter ❑Open Bottom Gravel Pack/Gravel Size _In diameter <br /> U Conductor Casing In diameter / Conductor Casing Depth fl <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad[;/2M 0 Steel APlaslic ❑Stainless Steel ❑Other <br /> Grout Seal Depth /O/J It 0 Neat Cement(941b bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) D Other ' <br /> Grout Placement Method Bumped ❑Free Fall D Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 DrillerUmp Contractor ❑ Other <br /> 0 Concrete Pedestal ODI nenslons:Width__4,_R Lenglh__ ,7 ft Thick In D Christy Box D Stove Pipe <br /> PuraP ubmersible0 Turbine 0 Other HP Pump Sel %/7D R Standing Water Level S Y-tl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITfi 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 /> MI B ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7sp 6 <br /> �(fJI�J/�' �J/ fjJ�/ <br /> SIGNED 'f'/! �"f�Z�� — ._ ���"�— � .. nAZ�_ / <br /> 4 )J982� Leuw rLD <br /> r <br /> - <br /> -- <br /> 3.5 <br /> � z <br /> PARTME103 e <br /> N T U E /O,NA L Y <br /> Application Accepted By Dalej// Area__ Employee 0# <br /> Grout inspection By Dale /// f I $ CII Permit <br /> Pump Inspection By Dale LI WAIVER Received <br /> Sell Boring Ins ecIto�1�nBy""" D I,— <br /> / Constructed Well Depth _ fl <br /> COMMENTSc _ _4QS.LJJ>; -- <br /> PE SC Received <ZC Amount Dale PermlU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> ZO 3 I (�1 03 3 <br /> s`oVC 713 1 Ul 5 <br /> 1.3 t W 0. <br /> 13 l� In) <br /> HDM1S-06 6/118019 WELL[PUMP PERMIT <br /> r u L r M R I IYI C 14 1 V 0 v IV L T <br />