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•� WELL/PUMP PERMIT F <br /> ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EX IRES 1 YEAR FROM DATE ISSUED <br /> � N <br /> JOB ADDRESS Q CITY/ZIP o 9•S3 !� LM <br /> m <br /> CROSS STREETS O� YoSF I• C /ole APN 2 YkrO 70 PARCEL SIZE V.� pLAND USE APP CATION# p <br /> OWNER NAME _ ! ✓T/ 'A l- rP,� O "P05- <br /> OWNER <br /> � rNn <br /> OWNER ADDRESS i /dd CITY/STATE/ZIP Wt/�f <br /> CONTRACTOR �J/+��♦T t .`/A O //PH�IONE (7 ,G+�� <br /> CONTRACTOR ADDRESS yL✓�/ 24 <br /> Air/�O L/ CITY/STATE/ZIP /L(•C/OG <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP q p <br /> LICENSE V-57 C-61 D-09 Other NUMBER 5/ /3 L EXPIRATION DATE 6--J 1 - / <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE fiTomestic/Private Irrigation/Agricultural 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 &✓New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical a of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method V lvlud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well DepthYO ft Excavation /2 Yr in diameter I Open Bottom gavel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diamete in Thickness/Gauge/ASTM Schad y� f� Steel vPrstic Stainless Steel Other <br /> Grout Seal DepthtQQ ft Neat Cement(94 lb bag0-10 gal water) Sand Cement sack mix17 gal water <br /> ✓Bentonite(20%solids) Other <br /> Grout Placement Method i-Pumped .Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length _ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft 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 /> �7 U JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> L 1 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERSMPENSATION LAWS. <br /> 2IV, MUM VANCE NOTICE REQUIRED FOR INSPEC <br /> TIONPL 71E CALL(209)953-7697 <br /> I _l SIGNED TITLE DATE • / <br /> It <br /> �A <br /> P TMENT �7SE ONLY /�/� <br /> 3'� Application Accepted By Date !i (� Area_C <br /> 'ti AL Employee ID# <br /> Grout Inspection By Date "j PECI WBII Permit <br /> Pump Inspection By Data WAIVER Received <br /> Soil Boring I spection By Date Constructed Well De h ft <br /> COMMEN <br /> ( �� �tgt/. TW <br /> PE SC Received Check#/ Amount age Permit/ Invoice# Well ID# � <br /> Code Info B Cash Remitted Service Request# <br /> qRtj <br /> ^rnys n ��y/3 <br /> 2v Q IIIMEH04}p6 8/O7/16 `7 ' � 1 LL/PUMP PE IT ' <br /> OV J J m �j <br />