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°r WELL/P.UMP;.PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> ' NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED <br /> lN <br /> JOB ADDRESS U l.� u. A V\ CITY/ZIP U �f i fl m <br /> L D <br /> CROSS STREET APN 2d -00- U PARCEL SIZE G. ND USE APPLICATION# g <br /> OWNER NAME V,�— �( I r /� �I 1� ✓f Y)'l /I PHONE �U p y <br /> OWNER ADDRESS '`-', ��/` LQ G CITYISTATEJZIP l Q " !I //r <br /> f (� � fti'�h �1 PHONE �Z— , -I2lf <br /> CONTRACTOR '^ �/A� /firGI <br /> CONTRACTOR ADDRESS �, VP CITYISTATE/ZIP /r rod-�I t 9 I-'5-7 <br /> SUBCONTRACTOR __ PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE , C-57 ❑C-61 D D-09 G Other. NUMBER G EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING::1 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)[1 Arsenic(4393) <br /> INTENDED USE XDomestic/Private II Irrigation/Agricultural C Industrial C Water Quality Monitoring D Soil Sampling/Characterj�c M <br /> C Public Water System C — <br /> If different from Owner Water System Name Contact Name or Phone Number Mall <br /> TYPE OF WORK C New Well L eplacement Well G Well Alteration/Modification D Other <br /> r] tl of boon <br /> Monitoring Well(s) #of wells D Soil Boringtl of borings <br /> Boring(S) ❑Geotechnical�N.fnq <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repairh RQUIN DD <br /> D New Pum D Pum Replacement LI Pum Repair G Raise Well Casing �LTF/ ON'NEN UNjy <br /> WELL CONSTRUCTION ENj <br /> Drilling Method )qdud Rotary D Air Rotary U Auger ❑�pble Tool C Push Point C Other <br /> (Proposed Well Depth_21�;O ft Excavation in diameter D Open Bottom ,P(Gravel PacklGravel Size ,in diameter <br /> U ConducI Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter. in, Thickness/Gauge/ASTM Sched 7 C[ it Steel lastic fl Stainless Steel !]Other <br /> Grout Seal Depth /5E) ft L'Neat Cement(94 Ib bag/5-10 gal wafer) :;Sand Gement sack mix/7 gal water <br /> �,,Benlo ite(20%solids) C Other <br /> Grout Placement Method Pumped C Free Fall O Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller Pump Contractor D Other <br /> G Concrete Pedestal ODlmensions:Width ft Length R Thick in U Christy Box D Stove Pipe <br /> PUMP Ll SubmersibleC Turbine I'Other HP Pump Set ft 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 /> MIN 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> —� C� In f TITLE DATE 9 - <br /> - V— 1-7 <br /> �h C <br /> t t <br /> rr I <br /> ,h <br /> V <br /> J <br /> r <br /> L <br /> t <br /> PA TMENT USE PINLY /// �) <br /> Application Accepted B Date` Area Employee ID# 1.� <br /> Grout Inspection By Date 17 SPECIAL Well Permit <br /> Pump Inspection By Date !-I WAIVER Received <br /> Soil Boring Irrppection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Choc Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Re Itted Service Re uest# <br /> �l clWP 0 o 0OW)55 <br /> 1rJ 0 <br /> HL <br /> , .ILII 0 L0 <br /> WELL/PUMP PERMIT <br /> EHb a3-00 &011113 <br />