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WELL/PUMP PERMIT <br /> SAN'JI '— COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE PERMIT I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ��..� 20 yV • L'�"O`••'��'p`- "� CITYIZIP��`^�( <br /> CROSS STREET IPI Q.r RC1 APIN �('• r 3�//OQ�/,�7(� PARCEL SIZE LAPID USE �IJ TI^O�N# p <br /> OWNER NAME �c2 N'T�l �14'_i.50,�yr'V`''_• GQui P(HOONNEE �1 r G.�I0 vi <br /> wo <br /> OWNER ADDRESS `72�' L rCITY/STATE/ZIP `PHONE 5�za—/?'.'a <br /> � <br /> f 7�6 y <br /> CONTRACTOR ��r���f S' i4L LL!? �^ <br /> CONTRACTOR ADDRESS_ Q 416zIc S- Rd CITY/STATEIZIP YY 1 6Ile Sje' Jt-yI <br /> SUBCONTRACTOR PHONE 269 I/SZam��fl-6 <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE y C-57 0 C-61 0 D-09 0 Other NUMBER EXPIRATION DATE„.26-2/ <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE V Domestic/Private ❑Irrigation/Agricultural D Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> O Public Water System <br /> If different from Owner: Weler Syatem Name Contact Name or Phone Numbar <br /> TYPE OF WORK l ew Well ❑ Replacement Well 0 Well Alteration/Modification 0 Other 0of borin s <br /> 0 Monitoring Well(s) #of wells I]Soil Boring(s) K of bodnge 0 Geotechnical 9 <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pump ❑Pump Replacement ❑ Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method( Mud Rotary,, ❑Air Rotary 0 Auger O Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth_21F_ft Excavation/Z In diameter 0 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 27.x_ 0 Steel Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth /Dry ft D Neal Cement(94 Ib beg/5-10 gal water) D Sand Cement sack mixfl gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped Cl Free Fall 0 Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 4Z Pump Contractor D Other <br /> 0 Concrete Pedestal DDime slons:Width ft Length it Thick in 0 Christy Box 0 Stove Plpe <br /> PUMP 0 SubmersibleD Turbine 0 Other HP Pump Set It Standing Water Level ft <br /> 1 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE <br /> b <br /> ----------------- <br /> ' --------------- <br /> - �g 11 ' 22. c�1'1N <br /> EP RTMENT U E N L Y <br /> Application Accepted By Dale 7 Area Employee IO# <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Date Permit/ Well# Well 10# <br /> gC Into By ash Remitted Service Request# <br /> ) 1 0 <br /> jo <br /> bf <br /> WELL/PUMP PERMIT <br /> EHD 43-08 8101/18 <br />