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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 952 -(209)468-3420 <br /> NON-REFUNDABLE PERMITCALL 209 963-7697 FOR INSPECTIONS EXPIRES 1 YEAR FR M DATE ISSUED N <br /> �. CITY/ZIP a -- m <br /> JOB ADDRESS <br /> l'tsi o <br /> APN PARCEL SIZE i�fD-'d T� O`�LAND USE APPLICATION# y <br /> CROSS STREET �L► L� c f 0 <br /> OWNER NAME (tka�-, fwfsG�' AA 4 PHON r <br /> OWNER ADDRESS 64 4_)�RYISTATE(ZIP <br /> - <br /> A.0 tt ir,1 r • PHONE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS l CITY/STATE2IP„Ad aC d <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 D C-61 ❑D-09 (1 Other NUMBER EXPIRATION DATE <br /> j.J <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393 <br /> INTENDED USE DomesticfPrivate 0 Irrigation/Agricultural (:7 Industrial 7 Water Quality Monitoring L Soil Sampling/�ftzabon0 Public Water System Cornad Name or Phone <br /> If different from Owner. Water System Name <br /> TYPE OF WORK New Well Replacement Well 0 Well Afteration[Modification �Other_ a of borings <br /> #nI <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) a Geotechnical <br /> C1 Out-Of-Service Well Ci Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New PUMP 0 Pump Replacement 0 Pump Repair 0 Raise Well Casin <br /> WELL CONSTRUCTION <br /> DrlllLClIng Method�Mud Rotary 0 Air Rotary 0 Auger C Cable Tool ;:7 Push Point D Other <br /> Proposed Well Depth OO ft Excavation 12- in diameter (:7 Open Bottom XGravel Pack/Gravel Sze n diameter <br /> CI Conductor Casing in diameter / Condu�ctorCasing Depth ft <br /> Well Casing Diameter b in ThicknesslGaugelASTM Sched L.00 [:I Steel aplastic Stainless Steel L-i O er <br /> Grout Seal Depth_ <br /> ft Neat Cement(941b bag/5-10 gat water) ^:Sand Cement sack mixt gat water <br /> A($entonite(20%solids) (:I Other <br /> Grout Placement Method umped L'Free Fag 0 Other [!Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller Pump Contractor U Other ft Thick in 0 Christy Bo 0 Stove PIPs <br /> 0 Concrete Pedestal(:)Dimensions:Width ft Length <br /> 'PUMP r:l Submersible[]Turbine 1.7 Other HP <br /> Pump Set ft Standing Water eve] ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOF DANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RIEC JIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMMLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 53-7697 <br /> SIGNED ,�/� TITLEd r DATE <br /> S <br /> t <br /> a <br /> Ul <br /> r►w�q+µ D PA TMENT U E ONLY <br /> Application Accepted By Dale <br /> IS AreaE ployee INjO� <br /> Grout Inspection By Date J iPECI611 efflllt <br /> WAIVER Received <br /> Pump Inspection By Date <br /> o f ted Well De h v tt <br /> Soil Boring Inspect n By Date C <br /> COMMENTS V� <br /> Re ck ou Permit/ Invoice# Well 10# <br /> Codes o �i5"etc Remitted <br /> Date Service Re uest# <br /> 3? <br /> WELL/PUMP PERMIT <br /> PHD43-06 8701116 <br />