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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT WWW.S�/Ov.Of /ehd / _E1/XPIRE(�S/I YEAR FROM DATE ISSUED <br /> JOB ADDRESS Ove- frr0 1 CrTY/ZIP /�(J�1 _1 J 1 o m <br /> ARC <br /> CROSS STREET E 7,4#,,A P�_ PJ APN EL SIZE r�//C LAND USE/APPLICATION#1�'1, <br /> OWNERNAME cow+(-A1�SC�►st'n�t- log Tom" PHONE <br /> OWNER ADDRESS 11 !9 IT,, F CI_O,00,�_ WCrTY/STATE/ZIP <br /> {OW!' <br /> S l CONTRACTOR A ba,I I; ,�1f/ AY q y/ PHONE -SZp3dyQ <br /> 5t',J CONTRACTOR ADDRESS 5��G�►A " I / CITY/STATE/ZIP VtJ$4.;���cccp���Gr42!q�/A�i CA <br /> CV e,T rQCTp ` - // :"L � . PHONE ��/ 7':I-5 OD <br /> SlIBG6NiAAeTOWGONIiULiYW6 C7��N. I.OVLSIn N <br /> Curt ch 1,8� uB_G SI -r } p''Tw <br /> SsQ6��sg 5ficTE ► CC+ <br /> LICENSE )(C-57 C-61 D-09 Other NUMBER <br /> jt6050 EXPIRATION DATE W Z0 <br /> BILLING PARTY: -OWNER -CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:C General Mineral/Coliform Bacteria(4391)E Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE C Domestic/Private E Irrigation/Agricultural C Industrial G Water Quality Monitoring Soil Sampling/Characterization <br /> C Public Water System <br /> If different from Oaner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK E New Well - Replacement Well -Well Alteration/Modification Other <br /> E Monitoring Well(s) #of wells Soil Boring(s) #of boringsJd�Geotechnical 2 #of borings <br /> E Out-Of-Service Well E Out-Of-Service Well Renewal -Cross-C?nnection Repair <br /> F New Pump Pump Replacement =Pump Repair G Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method C Mud Rotary Air Rotary X Auger - Cable Tool - Push Point Other <br /> Proposed Well Depth ZO 1 ft Excavation 60 in diameter G Open Bottom -Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter t Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched E Steel Plastic -Stainless Steel E Other <br /> Grout Seal Depth SO' ft X Neat Cement(94 Ib bag/5-10 gaf ater) E Sand Ce m nt sack mix17 gal water <br /> C Bentonite(20%solids) =Other VA 11101 VV 1 S. em CIO iA <br /> Grout Placement Method C Pumped Free Fall =Other E Retardant/Accelerator(name) <br /> PEDESTAL Installed By =Driller - Pump Contractor - Other <br /> C Concrete Pedestal Dimensions:Width ft Length ft Thick in -Christy Box - Stove Pipe <br /> PUMP E Submersible=Turbine - Other HP Pump Set it Standing Water Level It <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 COMP TION LAWS. <br /> MIN Uip DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED RLE DATE <br /> �000 <br /> 1*4I Vii it X_ FTI <br /> CENr <br /> C ��� <br /> Tol <br /> RTME'`rT rlc,F^ONLY <br /> Application Accepted By Uv - Datt .X.✓/ ' Area �^'t T' Employee ID# � <br /> Grout Inspection By _ Date iii - SPECIAL Well Permit <br /> Pump Inspection By �y���Date - WAIVER Received <br /> Soil Boring In pection B � V1l7bQ 'C^'\Datet\m Constructed Well De h ft <br /> MMENTS Il O r C <br /> PE Sc Received Check## Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re uest# <br /> 15 <br /> EHD43-06 6,:12019 .I D 0 t U� WELLPUMP PERMIT <br />