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t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)4683(20 <br /> NON-REFUNDABLE PERMIT CAL Lff 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Jos AmREss 1 L 13 elCmP a n C�, <br /> a <br /> CROSS STREET�IOr'(i/J lif/C�ry�/ APN I� PARCEL SIZE LAHO Ua�APPuCATrm 1t p <br /> OWNER NAME / / ^ -I �j✓t 2 SC--1 PHONE U1�O �o-70.1f0'�o <br /> OWNER ADDRESS CITYISTATE,71P Yn�t ✓1 / CL'C �l qC r� —. . <br /> CONTRACTOR -311 vLl- 9Q1l-S L.�d'� 7 PHONE �r 1l 0. 7 <br /> CONTRACTOR ADDRESS S V v / CrTYiSTATVZIP (y�/)/�ryt�r ry 7.0.rC <br /> �r <br /> SUBCONTRACTOR PHONE <br /> 7 <br /> jSUSCONTRACTOR ADDRESS CITY/STATFIOp <br /> pug / f <br /> LICENSE C-57 1 D-09 Other NUMBER�D�0?7 Rep RATION DATE iZ/ !�1J��j ! L V <br /> DOMESTIC WELL SAMPUNG: General MineraVColiforrn Bacteria(4391) 'Dibrornochloropropane(4392)[7 Arsenic(4393) <br /> INTENDED U-r ❑Domestc/Private C;IrrigationtAgnoultural t!Industrial Water Quality Monitoring Sal Sampling/Characterizabon —1 <br /> C Public Water System J <br /> ll dle.rent I—Owner: Wel.,sy.t.m Nemo Contact Nw u w Phase Number <br /> TYPE OF WORK fl Now Well Replacement Wel _Well AileratiorvModification Other <br /> .,7 Monitoring Wel(s) a of vrds =Sod Boringis) a°r b—p Geotechnical s of borvrge <br /> 7 Out-Of-Service Wel =Out-Of-Service Well Renewal _ Cross-Connecbc n Repair <br /> �- )(New Pump L Pump Replacement - Purrgl Repair - Raise Well Casmo <br /> W ELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary ,7 Air Rotary Auger Cable Tod is Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom Gravel PacklGravel Size in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter_in ThicknessJGauge/ASTM Schad �.Sled - Plastic a Stainless Steel r1 Other <br /> Grout Seal Depth ft 7 Neat Cement(94 lb bag5-10 gal water) Sand Cement sack mrx17 gal water <br /> Bentonde(20%solids) •J Other <br /> Grout Placement Method - Pumped i I Free Fall Other =Retardant/Accelerator(name) <br /> iPEDESTAL Installed By _:Driller (:1 Pump Contractor 7 Other W <br /> Concrete Pedestal�Dimerrslons.Width ft Length ft Thies in f Christy Boz 7.Stove Pipe <br /> PUMP Submersible Turbine Oprer HP I`-1P Set ft Standing Water laud A <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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM LJR ADVANCE NOTICE REQUIRED FOR IJN�SPECTIONS-PLEASE CALL(209)952/-7697 C, <br /> SIGNED G TRLE ,: t�✓Y)�� DATE f ZL I l <br /> .r <br /> 1 fifty r <br /> Eror <br /> EQ RTMENT U E N Y <br /> Application Accepted By A& Date Area C Employee IDaA•1=- " fsF�� <br /> -z <br /> Grout Inspecton By Dale .: SPECIAL Well Permit <br /> Pump Inspection ByDate : WAIVER Received <br /> Sod Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received ChectlY Amount DatePermiU InvoicaR WedlDk <br /> Co Info B Cash Remitted Service Request a <br /> Zo W 00 00 <br /> EHO..x0. .A1n8 WELL rPUPAP PERMIT <br />