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WELL/PUMP PERMIT <br /> S JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED rn <br /> FCROSSSTREET <br /> ` 1 `' I I`C Y� CITVIZIP I FA. <br /> D <br /> 10 <br /> CAr01 r. APN 2`1 S 3 X36-y� PARCEL SIZE E APPLICATION# <br /> m <br /> G la�1'4c j< un6 Z �h�c11-92 PHONE95 (��17 ff I►,1\G1�1 1'�(1 I D CINISTATEIZIP �Ra r 453'/6Q <br /> I�IASe(�Ir Vfl[\l`- 1 IAC PHONE <br /> CONTRACTOR { 1 /++ �J ,1{ d{` <br /> CONTRACTOR ADDRESS L I°I h I De l•S R I'^ CITYISTATEIZIP yr___ <br /> PHONE <br /> SUBCONTRACTOR <br /> CITYISTATE/ZIP <br /> SUBCONTRACTOR ADDRESS NUMBER 160EXPIRATION DATE `l(/—+'jG <br /> LICENSE C-57 0 C-61 D D-09 ElOther <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> r!!!:� <br /> omestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ <br /> Sail Sampli=./Number <br /> erization <br /> ublic Water System Vyeler 5 slam Name Contact Name or Pf•o <br /> different from Owner: y <br /> New Well 0 Replacement Well O Well Alteration/Modificallon ❑Otther <br /> TYPE OF WORK �, sol rIe <br /> ft of borings <br /> 0 Monitoring Well(s) #of wells D Soil Boring(s) ❑Geotechnical <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connectlon Repair <br /> 0 New Pump D Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method D.Mud Rotary 0 Air Rotary D Auger ❑��pto Tool 0 Push Point ❑ Other <br /> Proposed Well Depth ?260 Excavation / In diameter 0 Open Bottom 'A Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> ❑Steel lastic 0 Stainless Steel ❑Other <br /> Well Casing Diameter.�I Thickness/Gauge/ASTM Schad�_ � sack mix/7 al water <br /> Grout Seal Depth 20 H ❑Neal Cement(94 Ib bag/5-10 gal water) <br /> ❑Sand Cement g <br /> UAentonite(20%solids) D Other <br /> Grout Placement Method umped D Free Fell ❑Other ❑Retardant I Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ump Contractor 0 Other <br /> 0 Concrete Pedestal ODI enslons:Width ft Length ft Thick In ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submerslble0 Turbine ❑Other <br /> Hp Pump Set fi Standing Water Level ft <br /> H SAN <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL DONE IN ACCORDANCE WIT <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 /> MI J)1Aj,lM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76 97 a' <br /> ��- TITLE Cr. nj l' DATE / <br /> SIGNED <br /> A� <br /> 1, <br /> yy / <br /> 4 J' <br /> A <br /> N / C <br /> D A <br /> F T <br /> DE ARTMENT USE N L Y <br /> AreaEmployee ID# <br /> Application Accepted By <br /> Date ( ` _ <br /> Grout Inspection By <br /> Dale ❑ SPECIAL Well Permit <br /> Date LI Received <br /> Pump Inspection By ft <br /> Soil Boring Inspection By <br /> Date Constructed Well Depth <br /> COMMENTS <br /> Amount Permit/ Invoice# Well ID# <br /> PE SReceived h Date Service Request# <br /> Codes Info <br /> o B Cash Remitted <br /> •� 3?? o I Z t� �0 ? <br /> -o <br /> WELL(PUMP PERMIT <br /> EHD 43-06 BMWs <br />