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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 45205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'We- 7 4al e ;nz!ee CITY2lP_�� m <br /> CROSS STREET APN GN 7-(..{Jy /I PARCEL SIZE6•q-/LAND USE APPLICATION[#; o <br /> OWNER NAME (/YTV�d IV PHONE V 71 f in <br /> rn <br /> OWNER ADDRESS CITY/STATFJLP <br /> CONTRACTOR (l/�R (C-'G D <br /> PHONE <br /> CONTRACTOR ADDRESSS� t t^ty r't 7[ - CITY/STATE/ZIP L-•�/7/�Cl'�; ry .j <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ,.� <br /> LICENSE _. C-57 1161 D-09 Other Z NUMBER 7 ExPIRATON DATE 30'-'-Z <br /> DOMESTIC WELL SAMP G:-General MineraVColiform Bacteria(4391):=Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ~ omestic/Pnvate -Irrigation/Agricultural =Industrial I Water Quality Monitoring Soil Sampling/Characleri7alion <br /> ---] <br /> _ Public Water System <br /> II diner..from Omer Water Systom Na"re Cunmct Na--ni Phone Nuitdler <br /> TYPE OF WORK =New Well -Replacement Well Well Alteration/Modificalion =Other <br /> Monitoring Well(s)- _#of wells -Soil Borings) If of t1Ofl", =Geotechnical #of t nonos <br /> Out-Of-Service Well _Out-Of-Service Well Renewal 2 Cross-Connection Repair <br /> Pumv Pump Replacement =Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary -Air Rotary -Auger 'Cable Tool Push Point D Other <br /> Proposed Well Depth ft Excavation in diameter -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 Sched -Steel -Plastic Stainless Steel _Other <br /> Grout Seal Depth fl Neat Cemenl(94 lb bagl5-10 gal water) _Sand Cement sack mi+rll gal water <br /> Bentonite(20%solidsi = Other <br /> Grout Placement Method :. Pumped Free Fall - Other =Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _:Pump Contractor - Other (+ <br /> =Concrete Pedestal_Dimensions Width I Length ft Thick in _Christy Box -Stove Pipe <br /> PUMP ubmersible.. Turbine _Other HP Pump Sel lL�2- R Standing Water 4- <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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> if AICIUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED,'J •,�r e� J _ <br /> TITLE_ W i'I-P�2 DATE <br /> I � - <br /> I IT <br /> 4 ' <br /> CT � � 2014 <br /> ] JI 11 111111 1 �111 111 -1 <br /> )RONM C TY <br /> OAQUE OUN <br /> ! H DEPARTMEN7- <br /> PA ARTMFNT U E 0P1 L Y /� <br /> Application Accepted By �rbale f Q yZArea Employee ID#)�04 <br /> Grout Inspection By Date _Well Permit <br /> Pump Inspection By f Date�1 r � +�( WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> o s Info B sh Rem-fitted ate Service R uest# Invoice# Well ID# <br /> WELLIPUAIPPERMIT <br />