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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTON AVENUE-STOCKTON CA 9S2BS$Z32(2O9)QG8-34ZO <br /> IR <br /> NON-REFUNDABLE PERMIT WWW-S OV.OT /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> �j D <br /> CROSS STREET U V AP �D PARCEL SIZE Lfatl_USE APPLICATION ICATITION <br /> / �L /y� N <br /> OWNER NAME f7fir7L� LoC�o PHONE / <br /> OWNER ADDRESS fl-el V CITYISTATEIZIP <br /> CONTRACTOR xlx� S U.vl /►yP�H}O�NEE _ <br /> CONTRACTOR ADDRESS AW CITY/STAWZIP <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS �� CITYCISTTATEIZIP <br /> LICENSE C-57 ;C-61 D-09 -Other/'�i()1- i NUMBER EXPIRATION DATE <br /> BILLING PARTY. -.OWNER !-CZ;NJTRACTOR _ SUBCONTRACTORICONSULTANT <br /> DoMLsTfc WELL SAMPLING:...General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)=Arsenic(4393) <br /> INTENDED USE v96meshcJPrivale =Irrigation/Agricultural -:Industrial -_Water Quality Monitoring _Soil Sampling/Characterization <br /> D Public Water System � <br /> It di#crenl hem Owner. water syame sl—Name Cnntad Nor Phone N—b., P <br /> TYPE OF WORK D New Well :?"'Replacement Well Well Alleration/Modification Other Cc A <br /> Ir t.""gti %nI twrings c /�� <br /> ❑Monitoring Well(s) #of wells G Soil Borings) "'Geotechnical <br /> ❑Out-Of-Service Well =Out-Of-Service Well Renewal =Cross-Connection RepairXf <br /> Z Pum _Pum Re acement _Pum Repair Raise Well Casing // <br /> WELL CONSTRUCTION U 2019 <br /> Drilling Method Mud Rotary J Air Rotary _Auger L Cable Tool _.Push Point Other SAN J AQ�///V ®/� <br /> Proposed Well Depth ft Excavation in diameter --Open Bottom r'Gravel Pack/Gravel Size in dr O coo T' <br /> Conductor Casing in diameter I Conductor Casing Depth ft LT pp�NTAt,r <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched -;Steel =Plastic ❑Stainless Steel Other <br /> Grout Seal Depth It E.Neat Cement(94 Ib bagl5-10 gal water) ❑Sand Cement sack mix/7 gal water T <br /> :_Bentonite(20%solids) D Other <br /> Grout Placement MethodPumped 7 Free all Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By _Driller Pump Contract - Other <br /> 11Concrete Pedestal-Dimensions:Width ft Length It Thick jz_Ll--in 7 Christy Box _Stove Pipe <br /> P.UMP P-giubmersible-Turbine a Other HP Pump Sel �R Standing Water Lcvel ft <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 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS C UPENSATION LAWS. <br /> -'aU"' lOE'?NO T ICE REQUIRED FOR INSPECT IONS-PLEASE CALL(209)953-76e:" <br /> SIGNED �� TITLE D--tt?'?1L� _ DATE <br /> L <br /> \ \l 7 <br /> ALJ TTL <br /> AR MENT USj0E OjN LY <br /> -� Application Accepted By v Nle - Area Employee ID# /9 <br /> Grout Inspection By Date _ PECIAL Well Permit <br /> Pump Inspection By Date r WAIVER Received <br /> Soil Boring Inspeclion By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received I CheckW Amount Permit/Codes Info B Cash RemitDate Service R uestlR InvoicetY Well IN <br /> P1 <br /> Y /ll /]//?� /V� WELL/PUMP PERMIT <br />