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WELL/PUMP PERMIT <br /> SAN JOAOUIN COON ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDA E PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �� e- � �'1(?`(�o S�L�Lf CITY/ZIP <br /> CROSS STREET W LX&(Z�� Rc• APN A9)'- <br /> O -56k PARCEL SIZE LAND USE APPLICATION# o <br /> rQ 1 (� m <br /> OWNER NAME U(►S�y/,�,A�AKr1 /6.y-j05i2:n,,r pe-sl�.�to OF �a4erey PHONE C63 l2�Z.-1-l� , <br /> OWNER ADDRESSPO`J ,V-`0 k{��-J 00 4 CITY/STATE/ZIP r)+e.�IL i{'-j --r `r� <br /> MiN <br /> CONTRACTOR W 1-/t'M PHONE �O - `n 4 i7 <br /> CONTRACTOR ADDRESS I Q� If(S CITY/STATE/ZIP Cx-i (A , '71 6 <br /> 3 2— <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP '^ <br /> LICENSE C-57 a C-61 L D-09 L Other NUMBER U EXPIRATION DATE Tic, ZO O <br /> DOMESTIC WELL SAMPLING:LI General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)I_l Arsenic(4393) <br /> INTENDED USE ❑DomestiC/Private F. Irrigation/Agricultural F1 Industrial ❑Water Quality Monitoring XSoil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well -Replacement Well Well Alteration/Modification C Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings XGeotechnical #of 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 j(puger 1 Cable Tool -Push Point rl Other <br /> Proposed Well Depth(C+2r-1 It Excavation--in diameter -Open Bottom i Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched n Steel Plastic i Stainless Steel D Other <br /> Grout Seal Depth 1Q -V' ft ,Neat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> -1 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-Dimensions:Width ft Length ft Thick in -Christy Box -Stove Pipe <br /> PUMP Submersible._ Turbine - Other HP Pump Set It Standing Water Level It <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 /> �IDIJMUM 48 1 ADVANCE NOTICE REQUIRED FOR INS CT ONS-`PPLEEASE CALL(209)953-7697 <br /> SIGNED rf/ jTITLE vyi <br /> IY ,exr DATE <br /> T <br /> Ty <br /> V 104 <br /> I9 <br /> EA <br /> r <br /> E,gA TMUSE <br /> Application Accepted By Dateate Areafmployee[D#/� <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection B, Dae Constructed Well Depth ft <br /> COMMENTS f (f <br /> �� G{-�I � Y1 f S '�n'tlt, • <br /> PE SC Received (-CfiecW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By- --cl-sh Remitted Seryice a uest# <br /> 2VPK 1 <br /> EHD 43-06 revised 4114118 WELL(PUMP PERMIT <br />