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i <br /> I <br /> WELL/PUMP PERMIT <br /> SAN JDAG UIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAzELTON AVENUE-STOCKTON CA 95205-(209)468.3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 22�p T N1111�N R�• N <br /> JOA ADDRESS CfTYZP <br /> NNe �. - 11b. oho G — # <br /> CROSS STREET APN Ty,'�) PARCEL 91zE LAND USE APPLICATION# �7 tA� <br /> OWNER NAME � zGKI� A I V 11 PHONE 2,0 --403.2-499 �i I <br /> OWNERADDRESS IIS CITY/STATE/ZIP LI tVIM e� L�W ���y <br /> CONTRACTOR S� �yyl(p, PHONE ^A-( `(-t-`I17.0 <br /> CONTRACTOR <br /> ADDRESS CITYISTATEMP M KbIGA. <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C�IT(YISSTTA(}TEEIL�]P <br /> LICENSE C-57 D C-61 D D-09 0 Other NUMBER��W W'V�L�_ EXPIRATIDN DATE �•�' <br /> DOMESTIC WELL SAMPLING:❑General Mlneral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE 0 Domestic/Privele Inigallon(Agdcullural 0 Industrial 0 Water Quality Monitoring 0 Sol[Sampli=Number <br /> rization <br /> D Public Water System <br /> II dNrerent from O—r. Wrier Syllem Name Contact Name or Pho <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> D Monitoring Wells) #of wells D Soil Borings) <br /> t of boring, 0 Geolechnical 0 o bodna, <br /> D Out-Cf-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method AMud Rotary 0 Air Rotary D Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Wall Depth �VDIQ _11 Excavation i—In diameter 0 Open Bottom Pack/GravelGravel S(ze n diameter <br /> n Conductor Casing In diameter I Condu for Casing Depth it <br /> Steel 0 Plasllc D Stainless S eel 0 Other <br /> Well Casing Dlemeter��In Thickness/Gauge/ASTM Schad r <br /> Grout Seal Depth� ft 0 Neat Cement(94 Ib bog/5-10 gel wafer) Sand Cement `0.-191 sack mixl7 gal water <br /> ❑Bentonite 20%solids) D Olhar <br /> Grout Placement Method Umped 0 Free Fell 0 Other D Retardant/Accelerator(name) _ <br /> PEDESTAL Installed By D Driller 0 Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimensions:Width R Length it Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible❑Turbine 0 Other HP Pump Set R Standing Water Level ft <br /> 1 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FORINSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED <br /> TITLE lYLwl�p��ll� DATE <br /> I <br /> P YMFNT <br /> ece/V Fb <br /> PR 14 ?010 <br /> I ov( <br /> DE q�rz L N <br /> ENT <br /> I <br /> r f DEPARTMENT USE ONLY 4 <br /> ApplicellonAccepledBy ` /Zz Z Date N �l� ��4`� Area l� EmployeeID# �/ 1 <br /> Grout Inspected By Dale O SPECIAL Well Permit <br /> Dale ❑ WAIVER Received <br /> Pump Inspection By <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Recolved CheckM/ Amount Data PermlU Invoice# Well IDM <br /> Codes Info Cash Remitted ServlceRe uesttY <br /> y I yjv L `TL _ <br /> I <br /> 1110f/la A07079 2/�o <br /> WELL(PUMP PERMR <br /> EHDel-0e <br />