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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209(468-3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/etid EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /n CITYZP [stn <br /> CROSS STREET,bl AP a(2!2--h/0 V/—PARCEL SIZE I LAND USE <br /> _. `ArPPLICATION9 <br /> OWNER NAME PHONE J /V "V !g <br /> OWNER ADDRESb6lg AmL CITYISTATFZPuI0Qi6 CiIq Q3bCl <br /> O <br /> CONTRACTOR �/�/j7ry��P�77HH���O/NE f/�� //31 LL3dy C) <br /> CONTDM."rAnAOnnCCC CITVl.QTATF171DC)f(,[_k-hr C/T/�-Jl L��Qr_1 <br /> SVBCONTRACTORICONSUL7AN7 S PHON0,69'^�5 -- 'l 36 <br /> SUBCONTRACTORICONSU`LT,ANT ADDRESS LLq (C CITY/STATE/IIP 041 qj'�/ / <br /> LICENSE XC-57 }i!C-61 0 D-09 D Other NUMBER` E%PIRATION DATE T3/'pt l <br /> BILLING PARTY: /'`�I OWNER CONTRACTOR SUSCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:1 1 General Mineral/Coliform Bacteria(4391)1:1 Dibromochloropropane(4392)1 1 Arsenic(4393) <br /> DomeslltlPrivate 0 IRigallonlAgricullural D industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> O Public Water System <br /> riN� <br /> If&ferenl 1—Owner ~w System Name Cooled Nsme or Phone Number <br /> TYPE OF WORK P(New Well D Replacement Well D Well AlleratiONModifiration 0 Other <br /> D Monitoring Wells) #of wells D Soil Boring(S) s°i banner 0 Geotechnical e of bermes <br /> 0 Out-Of-Service Well D Out-Of-Service Wel Renewal D Cross-Connection Repair <br /> Now Pump. . 0 Pump Replacement 0 Pump Repair D Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 15AMud Rotary D Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth 33o R F-xcavaflon_[;;L in diameter U Open Bottom Gravel Pack/Gravel Size in diameter <br /> U Conducto/r_Casing in diameter r Conductor Casing Depth fl <br /> Well Casing Diameter_/O_in ThicknesWGauge/ASTM Schad A( o D Steel 75 Plastic 0 Stainless Steel U Other <br /> Grout Seal Depth_ (00 fl D Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> A Bentonile(20%solids) 0 Other <br /> Grout Placement Method S Pumped D Free Fall U Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 00 Pump Contractor 0 Other <br /> U Concrete Pedestal ODlmenslons:Width it Length fl Thick In 0 Christy Boz 0 Stove Pipe <br /> PUMP SubmersibieO Turbine 0 Other HP Pump Set­2-P0 it Standing Water Level15, N <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 /> MINI U 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECT[ S-PLEASE CALL(209)953-776977 <br /> SIGNED / TITLE DATE <br /> I ` <br /> V C U <br /> rF <br /> 4 <br /> E ARTME T U E ONLY -'� <br /> Application Accepted By Da Area Lam,//C�/-�F— Employee ID# <br /> Grout Inspecilon By Date SPECIAL Well Permit <br /> Pump Inspection By Date 1 WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received hae Amount Data Permit/ Invoice# Well[DO <br /> C d s t o B Cash Remitted ServIce Reauest# <br /> - - - r7 <br /> D <br /> EMD414)6 6r11r201e <br /> WELL(PUMP PERMIT <br />