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WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DFpwruENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 5232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.siqov.orqIehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS N <br /> CTTY(ZIp <br /> Ari esy d �s 6 p <br /> CROSS STREET /�V•c ,r/r f�,�//j�e�}�pP ,i `/gRCEL SIZE�J7SO ��USE APPLICATION E r [� p <br /> 0vmERNAME .J7/�/L//C fL� <br /> OwA z ADDRESS / / " <br /> CITY/S7ATE/Z1P <br /> C-OafTRACTOR l/l/ PHONE <br /> COKMCTOR ADDRE55 0TYIS7ATE2P <br /> 51LIIBP]NTRAGTOR/CON51.11_TANT �� .6521�/iy7 PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CTTYISTATERIP <br /> LICENSE )OC-57 /OC-61 D-09 Other NuueER EYpIRAnoNDATE 2 <br /> BILLING PARTY: OWNER CONTRACTOR . SUB CON7RACTOPICONSULTANT �Aec <br /> DOMESTIC WELL SAMPUNG:':General Mineral/Colrform Bacteria(4391) Cfbromochlcropropane(4392) Arsenic(4393) C�i��` <br /> INNO <br /> tEED USE omestiUPrivate Irrigation/Agricultural Industrial Water Quality Monitoring 'Soil Sampling/Characterazu <br /> Public Water System 0 <br /> II glferent from <br /> Omer. WaterSystem Name Contact Name or Phone Number <br /> TYPE OF WORK New Well "Id'-placement Well -Well Alterabon/Modi6calion Other Q IQ/ 2020 <br /> Monitoring Well(s) #of wells Soil Boring(s) e of bodngs u of bo N <br /> �Geolectmiral C <br /> ojj <br /> Out-Of-Service Well Out-Of-Service Wel Renewal :Cross-Connection Repair ThO N 'r <br /> New Pum - Pump Replacement Pump Repair Raise Well CasingT M <br /> WELL CONSTRUCTION <br /> Drilling MethodA&IudRota r Rotary • Auger Cgble Tool Push Point Other <br /> Proposed Well Depth_ tl Excavation_12'1 in diameter I Open Bottom ravel Pad JGravel Size in diameter <br /> Conduct Cneing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad�ZSteel��fasuc 1 Stainless Steel :Other <br /> hGrout Seal Depth Neat Cement(94 1b bag/Si0 gat water) Sand Cement sack&W7 gal water <br /> Bentonite(20%solids) :Other <br /> Grout Placement Method Pumped Free Fall , Other Retardant/Accelerator(name) <br /> PEDt'STAL Installed By 'i Driller I-Pump Contractor iOther <br /> Concrete Pedestal_Dimensions:Wdth_ft Length ft ThKkin Christy Bax l Stave Pipe <br /> PUMP ubmersible. Turbine ,Other HP Pump Set R 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 /> WORKERS COMPENSATION Is. <br /> P;111"l1 i Ir. c NOTICE REQUIRED FOR SPECTIONS-PLEASE CALL(209)9S 76r, <br /> SIG TITLE <br /> DATE <br /> � I <br /> I fT <br /> I <br /> i <br /> � I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date V30/"0Z'0 <br /> AArea f Employee IDtk <br /> JCr C�Ir fc'/ <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By Date L WAIVER Received <br /> Sol Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Da Permit] <br /> Codes Into as Remitted Service Request# Invoice 0 Well IDN <br /> L4�G1 / a/ S <br /> 3�d / <br /> �369 Teo Z IM Jy;() O <br /> �138O O O So? <br /> n' <br /> FHD 13.0p an1/HI�Y t <br /> WCLL RUMP pERMR <br />