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WELL/PUMP PERMIT <br /> t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205•(209)468-3420 <br /> t <br /> NONr_ REN FUNDAB PRI 1� CALL(2091953-7697 FOR INSPECTIONS 111 EXPIRES 1 YEAR FROM <br /> P <br /> JOB ADDRESS `' v CITY on/// `C m <br /> D <br /> CROSS STREET t APN 0 ARCEL SIZE APP p <br /> ✓ M <br /> �[J OWNER NAME �- T,� Vi f77�? 0 <br /> I • j <br /> OWNER ADDRESS [b 0 <br /> jCONTRACTOR v/J /pump'sCCC pH�� S <br /> CONTRACTOR ADORE b T M, (''� <br /> SUBCONTRACTORVIA PHONE (Z <br /> ,,SUBCONTRACTOR ADDRESS,_. CITY/STATE/?JP C <br /> ,LICENSE C-57 C-61 D-09 Oth —)Z—L-- NUMBER. EXPIRATION DA <br /> DOMESTIC WELLS PILING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agdcultural Industrial Water Quality Monitoring Soil Sampling/Charactenzation S <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 AiterationiModification Other <br /> Monitoring Well(s) #of wells Soil Boring(S) a of borings Geotechnical #of borings <br /> Out-Of-Service WeJy Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump r-mo Replace men Pump Repair Raise Well Casino <br /> !WELL CONSTRUCTION ^ <br /> ;Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_In Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water ^ <br /> Sentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> oncrete Pedestal Dimensions:Width ft L n t ft Thick in Christy Box Stove Pi <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft (1 <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 ACTH TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL 0I"1 <br /> WORKERS COMPENS N LAW t t <br /> MINIMU ADVANCE NOTICE REQUIRED FO�JI�SN/$]J�P�E/C�TIONSS--PLEASE CALL(2 +/r�/q 7 W <br /> SIGNED TITLE <! /6 1 1 L Vl DATE C. <br /> I <br /> AY4fI <br /> IF I <br /> 16°1 411 N41 �d�9 <br /> An L <br /> CJU/N <br /> pqRc <br /> O <br /> t � ��r' <br /> PSA TMENT U E O L <br /> Application Accepted By ate 14VI <br /> Area 't_� Employee ID#� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By!�,+t� �i�LQK'A0A Date , WAIVER Received <br /> Soil Boring Inspection By Date Constructed'Nell Depth__ C <br /> COMMENTS <br /> PE SC Received ec Amount Pertrtit/ <br /> odes Info ash itte Duarte Service uest# Invoice# Well ID# <br /> IV 1 Re 51 <br /> =-tiD 43.06 s;01116 <br /> WELL/PUMP PERNIT <br />