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WELL/PUMP PERMIT <br /> SAN.IOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT. 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205•(209)468-3420 <br /> NON-REFUND LEPERMIT <br /> /� CALL 209 953-7697 FOR INSPECTIONS EXPI ES 1 Y /FROM ATE ISSUED <br /> JOB ADDRESS C 6'l A + I 1y►rf� cnfi � yl I[TD7 <br /> ion <br /> CROSS STREE e' "'APN(�(iq-W�+—�7"PARCEL Ste`L € PLICATION K p <br /> / Th✓-1/7�u mn <br /> OWNER NAME � •VI`L+ P N� <br /> OWNER ADDRES (OZU w r, / CITY/ TA 4IP)y/��• X� �j /) <br /> CONTRACTOR2 , I 1 PH(yl� "I Q V a <br /> CONTRACTOR ADDfff/y�yS/b <br /> SUBCONTRACTOR •' I PHH/QHE <br /> SUBCONTRACTOR ADDRESS , ip— STATE/ZIP •- • _ <br /> L,CENSE C-57 C-61 D-09 Other 02j UMBE� ExPIRATION AT <br /> DOMESTIC WELLS PLING: General Mlnefal/C011fOrm Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USEDamestidPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System S <br /> If 0ferent from Owner. Nater System Name Contact Name of Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration,Mocification Other e� <br /> Monitoring Wallis) of wells Soil9enrgrs, aofbonngs a dborings Geotechnical I� <br /> Ott-Of-Service Wel Out-O"-Service Well Renewal Cross-Connection Repair <br /> New Pump Pu p Replaceme Punp Repair Raise Well Casing <br /> WELL CONSTRUCTION p <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Too; Push Point Other <br /> Proposed Well Depth It Excavation in diar.e:er Open Bottom Gravel Pack/Gravel Size in diameter b <br /> Conductor Casing in diameter / Conductor Casing Depth h <br /> Well Casing Diameter_;n Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 It,bagr5-10 gai dater) Sand Cement sackmix/7 gal water <br /> Bentonite(20%solids) Other ` <br /> Grout Placement Method Pumped Free Fall Other -Retardant-/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other 0 <br /> Concrete Pedestal Dimensions:Width_ft Lent ft Thick in ,Christy Bos Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Setft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN I 1 <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE 15 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL _ (� <br /> WORKERS COMPEN TION LAWS. ^vj•r� <br /> MINI 4 HOUR ADVANCE NOTICE REQUIRED F1�y'nN/XG1P�E/C�TIIONS-PLEASE CALL(2 9) 513/)-7 97 <br /> SIGNED J TITLE ry f Y V U�_ DATL <br /> I � <br /> i <br /> 11A A All <br /> -_ 20& <br /> N <br /> /N <br /> rr <br /> - <br /> T i gRrFNT <br /> �- I <br /> P MENT U E O L Y <br /> e47Application Accepted By Cate / Area EmployeelD#� <br /> Grout Inspection By Date �pPECIAL Well Permit <br /> mp <br /> PuInspection By ate (�Z/l V/ WAIVER Received <br /> Soil Bonnd;n�s\pe[c�tion By (' y Date Constructed Well Depth ft <br /> D%IMENTS Y K.tA.. y�.♦�r 1 �� C <br /> ?r SC I Received Check# Amounti Date S Permit/ <br /> CoOsInfoOVA u Invoice# Well ID# <br /> CoOs Info <br /> i i I <br /> I <br /> i <br /> I <br /> c-.-=b•iE iC••3 WELL,PLA4P PERMIT <br />