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I <br /> WELL/PUMP PERMIT <br /> $AN 9OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT - 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE <br /> IPERMIT <br /> (� KALI I 209 953-7697,FOR INSPECTIONS' EXPIREE1S 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I 1s-1q lin il'� I` - CITY/ZIP L1y df'1 / ,./ 2-36 m <br /> H <br /> CROSS STREET -..^.f�1'•C.!=70{�"�E' - - APN D V5'6 7 y ~2-`� PARCEL SIZE 6"3 d6 LAND USE APPLIICATION# y/ <br /> OWNER NAME �1'CC�t�Y�tT C r 1 rL^oy)q ) Y _ ___ IS <br /> J r y <br /> -7z'7 <br /> OWNER ADDRESS ' I I I �U lM.��UC—fir[— I CITY/STATE/ZIP G'-4- �'�f `qtt ��"3"r�.I✓' <br /> CONTRACTOR M C1 S(F I I is b(' I 1 (h n�,�n� PHONE <br /> r' ��— 7 G1 <br /> CONTRACTOR ADDRESS I`I 1� �JC� r�i J - CITY/STATE/ZIP r" 'r_" r ice/ r, ci 53 <br /> SUBCONTRACTOR 'PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 ❑C-61 ❑ 17-09. ❑Other NUMBER LJ'��'�.1°.r EXPIRATION DATE "'�f✓`•=%f" <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)Lf Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner:-- - - Water System Name, - Contact Name or Phone Ndinber <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method ud Rotary ❑Air,Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 3 v d ft Excavation 12- in diameter ❑Open Bottom (Gravel Pack/Gravel Size " in diameter <br /> ❑ConquctCasing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C7 in Thickness/Gauge/ASTM Sched �• ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal pepth �00 ft' ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> Bento 'te(20°/solids) ❑Other <br /> Grout Placement Method'K <br /> Pumped ❑ Free Fall ❑Other, ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible❑Turbine ❑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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU.148 HOUR ADVANCE NOTICE REQUIRED FOR'INSPECTIONS-PLEASE CALL(20953-7697 <br /> SIGNED �^'Q-� -1 f1i TITLE /f DATE. -� <br /> -'r b t3 �-tb'1 i <br /> � S <br /> t <br /> n\ <br /> `� N O <br /> NTr <br /> H E <br /> EE_ <br /> r rD. P A T M E N,T U E�f0/NjL Y <br /> Date ' Area } Employee ID#' l// <br /> Application Accepted By I r <br /> Grout Inspection By Date ❑ SPECIAL Well Pernnit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring'Inspection By Date Constructed Well Depth ft <br /> COMM6(JTS <br /> PE SC Received CaPxk Amount Permit/ <br /> Co o B Cash emitted Date Service R uest# Invoice# Well ID# <br /> 3-7092- <br />