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f <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-62$2 (209)468-1420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/chd __ _ EXPIRES 1 YEARRI FROM DATE ISSUED <br /> JOB ADDRESS MIA M. CH,"P�* & <br /> n'A M D <br /> CROSS STREET tT� APN 2,11V V rQ�O��PARCEL SrZE LAND USF.APPUCATION# c <br /> OWNER NAME (��11e 1'�/� ,�/(r PHONE}2,�0a•q 5• V tO s�b <br /> 0.1.ADD. J%AAIV 0 I VrJl#1V-& fit CITYISTATE/ZIP0 C1`V- t4 1192101 <br /> 7 Nl <br /> CONTRACTOR �_%11*1 QS [*A1NA •IVI✓ PHONE204:92- -• I-fI�+Y <br /> CONTRACTOR ADDRESS ill 111 AS f CITYISTATEIZIP tADJ;(j&f E 'I✓!I <br /> SUBCONTRACTOR(CONSULTANT PHONE <br /> SUBCONTRACTOWCONSULTANT ADDRESS CIrY/STATE/ZJP <br /> LICENSEC-J7 1;C-61 D-09 Other NUMBER EXPIRATION DATE 30 O <br /> BILUNG PARTTY:` OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General MlnerallColiform Bacteria(4391)- Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE XDomeslictPrivale ImgationiAgrlcultural Industrial "Water Quality Monitoring 0 Soil Sampling/Characterization <br /> D Public Water System <br /> If d'wrl l from Ow Witter Sy31—Nemo C.0 Nerve or Phom Number <br /> TYPE OF WORK Xew Well C Replacement Well Well Alteration/Modification _Other �,•/� MFN T <br /> - <br /> Monitoring Well(s) #of wells Soil Bomlgts) e of hormP i-r Geotechnical a 19 borft. CCI <br /> Out-Of-Service Well I.Out-Of-Service Well Renewal rl Cross-Connection Repair a 8 <br /> _ND <br /> ew u <br /> ELL Pnk_ Pump Replacement .I Pump Repair D Raise Well Casing AR <br /> WCONSTRUCTION 2 <br /> Drilling Method Mud Rota 1'Air Rotary 7 Auger U Cable Tool D Push Point Other ?010 <br /> Proposed Well Depth—fl Excavation I_in diameter 'Open Bottom Gravel Pack/Gravel Size in die <br /> ^Conductor Casing n diameter I Conductor Casing Depth fl 'IEgL Il?0/ CC)O <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Sched�_ "Steel �PIazOc "�Stainless Steel i.!Other pEPq RTTq <br /> Grout Seal Depth <br /> ll Neal Cement(94 lb bag/5 10 gal water) Sand Cement sack mix17 gal water MENT <br /> Monte(20%solids) O Other <br /> GroutPlacement Method Pumped n Free Fall Other Retardant I Accelerator(creme) <br /> PEDESTAL Installed By N Driller C1 Pump Contractor 0 011ier <br /> Concrete Pedestal 0Dimensions:Width It Length it Thick in ❑Christy Boz J Stove Pipe <br /> PUMP '1 Subm_ersiblef i Turbine Other ___ HP Pump Set It Standing Water Level_ _ _4 ( <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORN 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 /> I ADVANCE NOTICE REQUIRED F P TIONS-PLEASE CALL(209 9 3-7697 <br /> SIGNED <br /> 7� <br /> ,r <br /> 3' <br /> r <br /> Application Accepted By L ate' Area } E nploy.•e Ox � <br /> Grout Inspection ByAit Date P CIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Sod Boring Inspecti0By Dale onstructed ell Depth R <br /> COMMENTS Air _ <br /> G <br /> PE Sc Recelvsd Chack*i Amount PerrniU <br /> Codes killo ash Remitted Datea R tarsi t Invoice III Well IDX <br /> Q� L <br /> EHD43 .Y11=9 / WELL?UMP PERMIT <br />