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r' WELLIPUMP PERMIT <br /> SAM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 2209 953-7697 FOR INSPECTIONS f <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> �.ti/ <br /> JOB ADDRESS c it CITY/ZIP a I Oft 'I� � 9 jf 21 v N <br /> m <br /> CROSS STREETf�M(1V /,p' I IyM APN �Stl V - �+' PARCEL SIZE LAND USE A/PFl7P-LICATION# S p <br /> OWNER NAME v PHONE ` 30 /��✓ N <br /> ��f�+ 'y�1� r CJ�j 7 '� N <br /> OWNER ADDRESS V I�Ct �+ 1' `^' r "" CITY/STATE/ZIPti\Wt 6O1 I �G4A r��'7J✓�jV (�! <br /> CONTRACTOR /V/A'�� �y� �I PHONE r\'l7�-�'�+�t�/�-. 21- HUI' <br /> CONTRACTOR ADDRESS 'ICA R,1/V s CITY/STATE/ZIPA WSju,CIA 1C�/7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> '{� Q 1 fny�� <br /> LICENSE C-57 ❑C$1 D D-09 ❑Other NUMBER YY lrG_ EXPIRATION DATE l7 1- - <br /> DOMESTIC WELL SAMPLING:L General Mineral/Coliform Bacteria(439 1) !Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural D Industrial r Water Quality Monitoring 0 Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from wner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well VWRepiacementweli 0 Well Alteration/Modification 0 Other <br /> ❑Monitoring Well(s) #of wells 0 Soil Boring(s) a of borings p Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement ❑Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rota 0 Air Rotary 0 Auger 0 Cable Tool l7 Push Point ❑ Other <br /> Proposed Well Depth ft Excavation 1 2� in diameter ❑Open Bottom XGravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter V in Thickness/Gauge/ASTM Schad 0 Steel Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth 100 It 0 Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> XBentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped 0 Free Fall Other L.❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box 0 Stove Pipe <br /> PUMP ❑SubmersibleC Turbine C Other HP Pump Set ft Standing Water Level k <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 /> DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)i9+53--7`697 f (} <br /> SIGNED MIN M 48 HOUR ATIT I I DATE <br /> oge <br /> t <br /> f <br /> J A <br /> Q N E <br /> � E <br /> DE A R TM E N I N L Y <br /> Application Accepted B Date Al, Area Employee IDt!I� <br /> Grout Inspection By i I I q Date 1 7 SPEC AL Well Permit <br /> Pump Inspection By t Date IJ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth C ft <br /> COMMENTS /11 7� r.1cyre �-(- C�� -I fl Z)0t �✓t ��p+3� <br /> PE S Received heck Amount Permit/ -1 / <br /> Codes I fo B s e itted Date eryice Re uest# Invoice# Well ID# <br /> 11PAV Ld P-001-221 /' <br /> EHD 43-06 8/01116 WELL/PUMP PERMIT <br />