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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT (� pCALL <br /> 209)953-7697 FOR INSPECTIONS /EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS T J Il.r J/�� •I e- P CITY/ZIP )C\C(\ <br /> CROSS STREET .`JTu C ✓�,}l,, I ,AI PN (()'1�.:.� -{'7Jt C, '1��PARCEL SIZE LAND USE <br /> ^APPLICATION iR O <br /> OWNER NAME .)��S r 1"1 r 1/ V"Cl.' XJrI F Y 1-S�I�h Ari' u)Cl C � �1 w <br /> PHONE I LUA—UG 1I m <br /> OWNER ADDRESS C' C' I (� -1 CITYISTATE/ZIP '"I ('(-V, (4" Q 9,3,-:?,; <br /> CONTRACTOR CONTRACTOR V r� �� l�r\ 11 \ L( PHONE 07 1 l W I C-.77 7 1 <br /> CONTRACTOR ADDRESS a(I X 9 r7t CITYISTATEILP ���I r L- 9 /c?t2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATErAP <br /> '"7�1 7 I <br /> LICENSE C-57 C-61 D-09 _. Other NUMBER`1�IC r E%PIRA TION DATE 7/ ( , <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omesbc/Pdvate - Inigabon/Agneultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 'p;New Well Replacement Well E Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells "-Soil Boring(s) a of tonnip f Geotechnical a of th nngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum `-1 Pump Replacement - Pump Repair L..Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method X Mud Rotary; r.Air Rotary I I Auger Cable Tool -1 Push Point Other <br /> Proposed Well Depth P- R Excavation� in diameter a Open Bottom ",,(Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth 11 <br /> Weil Casing Diameter In Thickness/Gauge/ASTM Schad t_�i"- n Steel y(Plastic Stainless Steel i Other <br /> Grout Seal Depth )Crrl It Neat Cement(94 lb bag/5-10 gal wafer) -)(Sand Cement )C 5 sack mix/7 gal water <br /> I Bentonite(20%solids) 1 Other <br /> Grout Placement Method X Pumped i Free Fall -Other n Retardant)Accelerator(name) <br /> PEDESTAL Installed By )4,Dnller !:Pump Contractor Other <br /> 7(Concrete Pedestal-Dimensions:Width It Length 7 It Thick in 7 Christy Box Stove Pipe <br /> PUMP X Submersible_j Turbine L Other HP 2 Pump Set L 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 COMPENSATION LAWS. <br /> MINIMUM 4`8'HOUR <br /> I AADVANCE NOTICE REQUIRED FOR INSPECTION,- -PLEASE CALL(209)953-7697 <br /> SIGNED /�/C•/"r' '\ TITLE F r{l t c�C t\ DATE 1 <br /> 4� <br /> C 1 C <br /> T <br /> L I- <br /> J <br /> S <br /> IL <br /> s \ ,c. C - <br /> 3 <br /> 1_ <br /> I <br /> 3 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Into B Cash Remitted Service Re uest# <br /> EHD4306 r sed411411t1 WELL/PUMP PERMIT <br />