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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELToN AVENUE-STOCKTON CA 95205-6232(209)468.3420 <br /> NON-REFUNDABLE rPEERRMIIT+ www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ���7 Y�'•y�,�.'p..�l` �"�y �'�Y�•/� Cm21P� /11" n <br /> CROSS STREET_(..(7Y'��� L %�Z#W APN Z�y—LT.{,�L"Iri PARCEL SIZE "J rILD USE APPLICATION SI _ <br /> OWNERNAME �i7Elr f•l`py � �p'r�7 E�.� (�PPHHOONE <br /> OWNER ADDRESS i(]�� w• ��J_ CIIYISTATNZ J0'1 , �CAlL��� /�•ry� `r� N <br /> CONTRACTOR �7�1Y7y� /���M' r`�/)�UyQ [ L`' ` ��P/H�ONN�E�L'7� ryAS'L r–L4 VG`S XID <br /> CONTRACTOR ADDRESS `'RJ JL„A 04?0 IAM �W ` 7 7 •7 B�J[o Crry/ST`ATEZP JtZ#4f*A �F/ <br /> SUBCONTRACTOR/CONSULTANT _4 L5 C nQ' (. 7l j fZS ��\PHH/O�NEE,0110 ��/� ` <br /> SUBCONTRACTOR/CONSULTANTADDRESS 7 �/ CITYISSTATTEIZIPY^t��V VA616-NA <br /> LICENSE 14C-57 0 C-61 ❑D-09 ❑Other_ NUMSERL11244 EXPIRATION DATE <br /> BILLING PARTY: O OWNER W-ONTRACTOR 0 SUBCONTRACTOR/CONSULT ANT <br /> DoMEsnc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropmpane(4392)0 Arsenic(4393) (� <br /> INTENDED Use DomesGdPrivate C Inigation/Agricultural ❑Industrial 0 Water Quality Monitoring )C Soil Sampling/Characterization •� <br /> PublicWater System ___ qy, <br /> BeNil fioln 0~. W.er system N— -- Cwpled Narrla or Phone Number <br /> TYPE OF WORN ❑New Well 0 Replacement Well 0 Well AHeration/Modification 0 Other )r <br /> O Monitoring Well(s)__ #cfwells pr SoilBorings) "Of wkvs )rGeotechnical sol'Wirl <br /> 0 Out-Of-Service Well Ll Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> U New Pump ❑Pump Replacement 11 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 0 Auger ❑Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth-10 ft Excavation L;2 in diameter I I Open Bottom ❑Gravel Pack/Gravel Size In dWnwt r <br /> 0 Conductor Casing—_in diameter / Conductor Casing Depth ft f1 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad ❑Steel n Plastic ❑Stainless Steel a Other_ <br /> 1 Grout Seal Depth_C-'10ft 14 Neal Cement(94 Ib bag3-f0 gal water) ❑Sand Cement„ sack mlx/7 gal water v <br /> Fl Bentonite(20%solids) 0 Other J <br /> (Grout Placement Method Lumped xrFrse Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller C Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dlmenslons:Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible❑Turbine 0 Other HP Pump Set ft 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 /> INIr1Uh^.i6 HT ADVANCj1NOTIC REQUIRED Ir OrgalN_S`P/E♦C�TION4S,-'PL_EAASSE_C�JALL(209)953-797 <br /> SIGNED , / J TITLE `JW{A.JGVs 6I1R-DATE<illa�� <br /> ENt,'�QiJi <br /> ENT <br /> P11 MEN7 Z LY <br /> Application Accepted B _ _ Dal( � AfM� Employee IDp <br /> Grout Inspection ByDate___��•{{{_ ❑ PECIAL BII Permit <br /> Pump Inspection By Date L I WAIVER Received <br /> Soil Boring Inspection By AaVT <br /> Data Constructed Well Depth f1 <br /> COMMENTS <br /> PE-- --SC Received Cheek#/ Amount Permit/ - __- <br /> s Info Ca ittad Service R uest N Invoke N Well IDN <br /> EHD 43-08 &It(W 1B WELL(PUMP PERMIT <br />