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1 ISo 1 <br /> WELL/PUMP PERMIT <br /> Q <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPART761ENT 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 /> ;JOB ADDRESS CITYlZIP GSCfiID Jv k.dale- m <br /> l �I� I �> <br /> CROSSSTREET CtIM.Q-.t61 M1lA• APN -� PARCEL SIZE�ANDUs'=AtPucnnUON# /50 I-� o <br /> OWNER NAME _ Ot°,\S1 G/���1 Qf/nY�S' PHONE Z09 I0Lf- I5t/ . <br /> OWNER ADDRESS ' 200 CcLr tf O<Q �T'• CITYISTATEIZIP CMAC Q �7 (� /�SZ <br /> CONTRACTOR A rD/11 J O 1.JLC• PHONE 0 I 1/1'5 • W`.2-7 <br /> CONTRACTOR ADDRESS [S (] -� J4(�y— (7 2J . CRYISTATElZIP M(AHj• G. r lA 95331,2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTYISTATEIZIp <br /> LICENSE :I C-57 XC-61 I'.D-09 II 011ier NUMBER EXPIRATION 75(o EXPIRATION DATE O 3} ZO L <br /> DOMEsnc WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391) I Dibromochloropropane(4392). Arsenic(4393) <br /> i INTENDED USE !,Domeslin'Prlvate Q Irrigation/Agricultural : Industrial i Water Quality Monilenng I Soil SamplinglCharaclenzation <br /> P Public Water System <br /> Irdllk-11 tram Cwnuc Warm system Nm,w 2-1-1 Nurnc m Pill-Nunibar <br /> TYPE OF WORK :!New YVell I I Replacement Well I I Well AllerationlModigcalion I I Other <br /> I Monitoring Well(s) #of wells 1;Soil Boring(s) aur loedllp : Geotechnical <br /> l I.Out-Of-Service Well I Out-Of-Service 1,P1ell Renewal ; Cross-Connecl:on Repair <br /> _ .New Pum !-i Pump Replacement Pump Repair I l Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method !;Mud Rotary i I Air Rotary I-.Auger I I Cable Tool I I Push Point I i Other <br /> Proposed Well Depth ft Excavation in diameter Il Open Bottom I I Gravel Pack/ ravel Size in diameter <br /> I Conductor Casing In diameter / Cunductur Casing Depth R <br /> Well Casino Diameter_in Thickness/GaugelASTM Sched I.Steel Plastic :Stainless Steel Other <br /> Grout Seal Depth fl :I Neat Cement(94 Ib bag/5-10 gal warer) 1 Sand Cement sack mix/7 gal water <br /> t I Bentonite(20%solids) I Other <br /> Grout Placement Method t Pumped i.1 Free Fall Other .I Retardant/Accelerator(name) <br /> PEDESTAL Installed By t.1 Driller :I Pump Contractor Other Elt r 1 <br /> I I Concrete Pedestal I!Dimenslons:Wdlh `jI R Length _H Thick = in :I Christy Box I:Stove Pipe <br /> PUMP ; Submersiblel I Turbine I 011ier HP i' Pump Selma It Standing Water Level <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 QALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEINSAT WS. <br /> MINI H ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> F <br /> SIGNED ter' TITLE ' �2 E / DATE <br /> PA <br /> V eD <br /> ! I <br /> 31 201, <br /> —— ViRO��N CoijN <br /> I NM Ty <br /> H c EIO-A <br /> D�o C <br /> — 1 - <br /> CN <br /> I T <br /> I II I <br /> _ II <br /> I I <br /> ��AENT U E NLV <br /> Application Accepted By Date/013 r Area Employee ID#� <br /> Grout Inspection By Date�— PECIAL Well Permit <br /> Pump Inspection By `•t Dale (C I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PESC Received Check#/ Amount I Permit/ Invoice# Well ID# <br /> Co s Info Cash Remitted Service Request# <br /> EHO d]-06 ieviuE mane wE,L/PVMP PEPMIT <br />