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WELL/'PUMP PERMIT „rn <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT '668 EAST HAZELToN AVENUE-STOCKTON CA 95205•(209)468-3420 ! I! <br /> NON-REFUNDABL ERMIT CALL 209 3-7$97 FOR INSPECTIONS IRES 1 YEAR FR DA sUEU V�I� <br /> CCB ADDRESS ) n 14 Crr rZjP V G i5 UU JJJ <br /> D <br /> CROSS STREET APN PARCEL SIZE , LAND U APPLICATION 3r / I o <br /> OWNERNAME "t/ L hic" ���f I✓~ tj (A PHONE V �� 1 w <br /> OWNER ADDRes U'� 'e)I� �r1 C A 11 a 957Z/i/ <br /> CONTRACTOR ��� V P �E 9 - (/ G <br /> I !, �^ 7 c <br /> CONTRACTOR ADORES 6 CITYISTA t+ L� -`� 17 7 <br /> SUBCONTRACTOR PHONE • 1ift Ii . <br /> SUBCONTRACTOR ADORES¢ I C-TWSTATErl.1 <br /> �V/ /, <br /> C <br /> L.cENSE -57 C-6*, D-09 Other ' NUMBE �\,E <br /> O 7 XPIRATION DATE Z V <br /> .DOMESTIC WELL S�iPUNG: General Mineral/Coliform Bacteria(4381 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE , Domestic/Pnvate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampli7g/Characteriza6on <br /> Public Water System <br /> if different fror•Owner. Nater System Name COMMM Name or Phone Number i <br /> TYPE OF WORN Nerr'JVell Replacement Well Well AlterationrMocifcation Other <br /> Momtonng'.Velltsj ;x of Wells Soil Bcr:rg:S, "bonn99 Geotechnical ��benr:ce <br /> Out-Of-Service II Out-OT-Service sell Renewal Cross-Connection Repair <br /> New Pump Pump Repla-amen Pump Repair Raise Well Casing j <br /> WELL CONSTRUCTION l <br /> Drilling Method Mud Rotary Air Rotary Auger CaDle-cc. DUSK Point Other 1 V l <br /> Proposed Well Depth ft Excavation in dianeter Open Bottom Gravel Pack/Gravel Size in diameterl <br /> Conductor Casing in diameter , Conductor Casing Depth ft <br /> Well Casing Diameter_:n Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag's-0 ga!•.rater) Sand Cement sack mix,17 gal water <br /> Bentonite(20%Solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Duller Pump Contractor Other 1 <br /> oncrete Pedestal Dimensions:Width_ft Length ft Thick in .Christy Box Stove Pipe <br /> ?UMP Submersible Turbine Other HP Pump Set It Standing Water Level <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> .:OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS , <br /> CURRENT THE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL n <br /> W COMP SATION LAWS. \t, <br /> M M �HOURADE TICE REQUIRED F INSPECTIONS <br /> -PLEASE CALL(2091"S3-769j <br /> SIGNE TI n V oto ti t' 1 DATE 1I <br /> t <br /> I I j G <br /> I I I I I i <br /> er <br /> PAyMjNr <br /> RFC :jVeD <br /> I <br /> 08 Z®f <br /> l l l I SCJ <br /> 0,AQUIN C <br /> I H�1LTy pE)WL, 7Y <br /> EP RTM U N L Y MENr <br /> X-AophCeaon Aeeeotee i3y � to Area Employee!D#�l-•a .y�r <br /> GroL:InspeC.lcn ay Dato SPECIAL well Permit <br /> °u^r Inspection By -A.— Date 10 <br /> WAIVER Received <br /> Scil Sonno Inspection By Date Constructed Well Depth <br /> 7:'RIcNTS tt <br /> PE SC Received Chec Amount Perm <br /> Co eS If. B ash emittec Date Service Re uest# Invoice# Well ID# <br /> i <br /> I <br />