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r <br /> r w" <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN 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 <br /> C— N <br /> JOB ADOREss Z(O ac//�J �r<n+,4']C� J .. /j CITY21P RC1 9 J Z <br /> CROSS STREET r/WV APN Z Z-?7gD ii/,I l PARCEL SIZE - LAND USE APPLICATION If <br /> OWNER NAME -5,25i: V PHOON <br /> OWNER ADDRESS �(/ � '// CITY/STATEIZIP 2!5/t /G/V <br /> CONTRACTOR ,u�°•� PHONE 2Z*— <br /> -- •l �� <br /> CONTRACTOR ADDRESS 1-910 tr�f CITY/$TATFIZIP jg/�'3 �t _ �f�3�yT <br /> SUBCONTRACTOR 1 PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE - C-57 t D-09 OtherNUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMP NG: General Mineral/Coliform Bacteria(439 1)-Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE omestic/Pnvate -Irrigation/Agricultural -Industrial D Water Quality Monitoring _Soil Sampling/Characterization <br /> -Public Water System <br /> If aiRerenl from Owner. Wale'System Name Conrad Name or Phone Number <br /> TYPE OF WORK -New Well _Replacement Well - Well AlteratioNModificatlon 7 Other <br /> -Monitonng Wells) #of wells Soil Bonng(s) 4.11,—g' - Geotechnical A of borings <br /> Out-Of-Service Well "- Out-Of-Service Well Renewal -Cross-Connection Repair <br /> ie'tri-ew Pump Pump Replacement -Pump Repair Raise Well Casing <br /> WELLCONSTRUCTION <br /> Drilling Method _Mud Rotary ..Air Rotary Auger Cable Tool -Push Point _. 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 It <br /> Well Casing Diameter in Thickness/GaugelASTM Sched 1�Steel Plastic Stainless Steel _Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) -Other <br /> Grout Placement Method Pumped Free Fall -Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By -Dnlier ;oiKiump Contractor - Other _ <br /> -Concrete Pedestal_Dimensions:Width ft Length ft Thick in Christy Box -Stove Pipe <br /> PUMP ubmersible-Turbine _Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 /> IMUM 48 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED «- TITLE 01i-t /t DATE <br /> IT <br /> 1-4 � <br /> FNp <br /> 3VP <br /> RTMENTnT US <br /> Application Amepled By Date ✓ (w Arear Employee ID# Cr+"Jr'14 <br /> Grout Inspection By r Date SPECIAL Well Permit <br /> Pump Inspection By Date I iJi <br /> U WAIVER Received <br /> Soil Boring Inspection By__ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amountite <br /> Permit/Codes Info B ash emitted Service Re uest# Invoice# Well ID# <br /> EHD43-Wr—,141WIS YJELL'PUMPPERMIT <br />