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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-REFUNDABL P RMIT www.slqov.orq/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> M rn <br /> JOB ADDRESS O • ITY/ZIP m <br /> ^V �/I D <br /> CROSS STREET 1.r Lf�10Y APN IL-1A�pp� PARCEL E2-,+LAND USE APPLICATION# o <br /> m <br /> OWNER NAME �Ofk 6 orb GKfi 6'r� PHONE w <br /> l to <br /> OWNER ADDRESS }fes 1�2 01 W- �d'���9�d�\ St• CITYISTATE/ZIP Qk,-*e!d keel ro <br /> CONTRACTOR KI a iv�'1 d,A A PPHONE.-9-ACI <br /> �A <br /> CONTRACTOR ADDRE 5 /' _ _� Y/►r �1Y 1(�" `6 CITY/STATE/ZIP �(4��✓r1'/ <br /> SUBCONTRACTORICONSULTANT (/ ,1 /I \/Y�, �� PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEMP Ch&eA <br /> � �LI��� Tl <br /> LICENSE \,--C-57 L C-61 C D-09 L Other NUMBER�` f � ►� EXPIRATION DATE <br /> BILLING PARTY: ❑OWNER V ONTRACTOR LlSUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)i.Arsenic(4393) <br /> INTENDED USE DomestictPrlvate -1 Irrigation/Agricultural D Industrial .Water Quality Monitoring oil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Nam or Phone Number <br /> TYPE OF WORK L New Weil -i Replacement Well U Well Alteration/Modification U Other <br /> C Monitoring Well(s) #of wells D Soil Boring(s) #of borings eotechnicai #of borings <br /> C Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> C New Pump U Pump Replacement C Pump Repair 7 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method LLMud//R� ryota�. D Air Rotary * uger C Cable Tool 11 Push Point = Other <br /> Proposed Well Depths —rn a ft Excavation in diameter U Open Bottom U Gravel Pack/Gravel Size in diameter <br /> D Conductor i5asing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched D Steel D Plastic 7 Stainless Steel D Other <br /> Grout Seal Depth ft 7 Neat Cement(941b bag/5-10 gal water) D Sand Cement sack m1x/7 gal water <br /> D Bentonite(20%solids) D Other <br /> Grout Placement Method dumped D Free Fall XOthearg / D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor :1 Other <br /> C Concrete Pedestal 0Dimensions:Width It Length It Thick in 7 Christy Box ❑Stove Pipe <br /> PUMP L Submersible Li Turbine -i Other HP Pump Set It Standing Water Level ft <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 COMPENSATIO LAWS. <br /> MINIMUM 48 R I ICE REQUIRED FOR INS CTIONS-PLEASE CALL(209)953-769 <br /> SIGNED TITLE t!�V I DATE C 6 <br /> �Cc P1111,1111.2 <br /> 1 78 11 <br /> 10 <br /> 016 <br /> Q <br /> T <br /> EPTMENT SONLY <br /> 10) <br /> Application Accepted By Date � Area Employee ID# � <br /> Grout Inspection By Data I ZC)2 O SPECIAL Well Permit I ' - <br /> Pump Inspection By$-' Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Permhl <br /> des Info B Cash Rennifted.. a e Service Request# Invoice# Well ID# <br /> EHD 43-06 8/1111019 Cf ; WELL/PUMP PERMIT <br />