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t WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209) _ <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM FROM DATE <br /> JOB ADDRESS O 171bus.--vi <br /> (y CITY21P <br /> CROSS STREET CCc,,,ST/,c I!/ l0 /APN r O-1 PARCEL SIZE LAND USE APPLICATION# <br /> 6 <br /> OWNER NAME r -/�L.n/Q 4 -.14/.�E/9✓ PHONE <br /> OWNER ADDRESS aS TOS! �G CITY/STATE21P 4,4e14.1% <br /> (C�y <br /> CONTRACTOR 6__0IL44.11 Sr prl /dire �'/a�•••P PHONt ?CT.) 7•.�- �7177y <br /> CONTRACTOR ADDRESS 9'j-0 U AN CITY/STATE/LP -L-0. /0-0-/V' �-0-�� 6* <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRY/STATE/ZIP <br /> f� i <br /> LICENSE :j C-57 )CC-61 ❑D-09 C Other NUMBER /��`�33 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED UsE XDomestic/Private -irrigation/Agricultural D Industrial ❑Water Quality Monitoring -Soil Sampling/Cheractedzation <br /> Fl Public Water System <br /> If different from Owner. Water System Name Contact Name m Phone Number <br /> TYPE OF WORK ❑New Well ,]Replacement Well -Well Alteration/Modification :7 Other <br /> C Monitoring Well(s) #of wells 7 Soil Boring(s) 1f of borings 7 Geotechnical a of borings <br /> Out-Of-Service Well �Out-Of-Service Well Renewal F Cross-Connection Repair <br /> New Pump r Pump Replacement ❑Pump Repair _1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r!Mud Rotary r Air Rotary - Auger r Cable Tool r-Push Point r Other <br /> Proposed Well Depth ft Excavation in diameter C 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 Schad L Steel g Plastic ❑Stainless Steel 0 Other <br /> Grout Seal Depth ft L Neat Cement(94 Ib bagl5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) c Other <br /> Grout Placement Method G Pumped - Free Fall F Other o Retardant/Accelerator(name) <br /> PEDESTAL Installed By a Driller a Pump Contractor Lj Other <br /> Ei Concrete Pedestal-Dimensions:Width it Length R Thick in ❑Christy Box Stove Pips <br /> PUMP )✓Submersible' Turbine r.Other HP Pump Set It Standing Water Level 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 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 /> MINIMUM 48 HOUR A VANCE ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9553-76997 (� <br /> SIGNED TITLE V17s y-/�../AN t:r DATEg. <br /> qyM <br /> CF�VNT <br /> F® <br /> 1? ?oy <br /> V)N C <br /> O pMou <br /> "r At <br /> NT <br /> DEP RTMENT E ONLY <br /> Application Accepted By Date.G r Z q Area Employee ID# _� <br /> Grout Inspection ByCZ— <br /> Data ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By D t Constructed Well Depth R <br /> COMMENTS GZ-5ckyCIr���bC al - 1 L=11 -A <br /> 426 <br /> PE Sc Received heck#/ Amount Permltl Invoice# Well ID# <br /> Codes Info Ca Date Remitted Service Request# <br /> 12z. - •12i� <br /> EHD 4306 revised 4114116 'Dv WELL h'UMP PERMIT <br /> :43D.00 <br />