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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)46"420 <br /> NON-REFUNDABLE PERMIT NWVW.S• OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / v CITY/71P <br /> CROSS STREET ,� FAAR L SIZE LANG USE APPLICATOM# o <br /> OWNER NAME p�(�//{-Z� �lAL-JL-�Vl/L✓7f� PHONE Vod♦ 507—e/7-—e/ a <br /> OWNER ADDRESS CITYISTATE/ZIP -{J(/�L. <br /> (CONTRACTOR 1 !'l�� /(/ � �GPHHOON.E�-� /4�1 ��1� <br /> (CONTRACTOR ADDRESS CITYISTATEJZIP_ <br /> r* J <br /> SUBCONTRACTORICONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS Cr YISSTA�TrEZP <br /> LICENSE *C-57p!�1 LI D-09 J Other NUMBER 0J 1 EAPIRATION DATE � Z <br /> BILLING PARTY: /�"•_1 OWNER 'CONTRACTOR ;! SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General MinerallColiform Bacteria(4391) Dibromochloropropane(4392)G Arsenic(4393) <br /> INTENDED USE omesticJPrivate -Irrigation/Agricultural Industnal P Water Quality Monitoring C Soil Sampling/Characterization <br /> I <br /> r Public Water System <br /> II dif.—I f—Owner W.I.,STetam Name ContaCt Name or Phone Number <br /> TYPE OF WORK/VNew Well I-Replacement Well Well Alteration/Modificalion 7 Other <br /> ',Monitoring Wells) #of wells ❑Soil Bonn s 'o1 ti "0n <br /> 9( ) ❑Geotechnical '°I°o^"o. <br /> i Out-Of-Service Well D Out-Of-Service Well Renewals Cross-Connection Repair <br /> ew Pump U Pump Replacement O Pump Repair ;j Raise Well Casino <br /> WELL CONSTRL16TION <br /> Drilling Method IYMud Rotary n Alr Rolary 7 Aupar n Cabla Tool r Push Point o Other <br /> Proposed Well/Depth ZOO If Excavation_�In diameter C Open Bottom �CGravel PadJGravel Size in diameter <br /> 0 ConductorCasing In diameter I Conductor Casing Depth R <br /> Well Casing Diameter_& in Thickness/Gauge/ASTM Sched rl Steel 7 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth %i%' ft C-,Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mixf7 gal water <br /> JeBentonile(20%solids) O Other <br /> Grout Placement Method Pumped a Free Fall 0 Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller VPump Contractor 1/- Other <br /> L Concrete Pedestal'--Di ensions:Width 7 R Length It Thick 5 In 0 Christy Box ',Stove Pipe <br /> PUMP r ubmersibleG Turbine 0 Other HP Pump Sel 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 /> 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 /> I WORKERS C EN TION LAWS. 1 �_w� `fe <br /> '✓Y q— <br /> MI U /NOJTIICCE REQUIRED FO NSPECTIONS-PLEAS CALL(209)95/3-7697 <br /> SIGNED �-Y�h�'r�� TITLE DATE <br /> I <br /> �n <br /> I tI 1 <br /> pq yMFN <br /> cF�VFO <br /> 7 c. <br /> a ?019 <br /> ! Q(qN <br /> C <br /> TMENT U O LLyy ,!��►��`//�(O--Rg C-At t <br /> Application Accepted By P Date l / Area Employee ID# RTi11�NT <br /> Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By Dale [l WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permit? Invoice# Well ION <br /> Codes i o By- C sh emitted Service Re uest# <br /> t) t9 7CI <br /> Oo 3 <br /> �� WELL M1'UMP PERMIT <br />