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WELL/PUMP PERMIT <br /> I � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAzELTou AVENUE-STOCKTON CA 95205-(209)468.1420 <br /> 1 <br /> � NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1/YEAR FROM DATE ISSUED <br /> i CrrvrZlP VL W <br /> Joe ADDRESS r <br /> APNµ O/0—IZ o <br /> CROSS STREET If�1�f/N`G NLIII�' �- PARCEL SIZE LAND USE APPLJCATIONN <br /> OWNER NAME �A An/nP,HONE <br /> OWNER ADDRESS J�/ c "1 ` AI CITYISTATEIZIP <br /> CONTRACTOR �/ ' PHONE (� � <br /> CONTRACTOR ADDRESS CITYISTATEIZIP 9r <br /> "V �%-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CtTYISgTATEILP <br /> LICENSE C-57 O C-61 D D-09 D Other NUMBER j nEXPIRATIONDATE o • 30 Z <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED U5E ameslictPrivale 0 Irrigation/Agricullural D Industrial D Water Quality Monitoring D Soil Sampling/Charectefizabon <br /> D Public Water System ' <br /> Irdleerenl from 0—r.. Wale,System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 0 Replacement Well 0 Well Allerallon/Modificallon 0 Other <br /> OMonitoring Well(s) #olwells D Soil Boring(s) eafbod"vs ❑Geotechnical 0ofbonnq' <br /> U Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connection Repair <br /> n D New Pump 0 Pump Replacement U Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> ry 0 <br /> er <br /> Proposed Wold Depthd7-00 D it RolaExcavation Auger 2„ Cable <br /> In dismal., Push <br /> 0 Open Olt <br /> Bottom X.ravel Pack/Gravel Size U In diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> D <br /> Wall Casing Diameter. In Thickness/Gauge/ASTM Sched S00 0 Steel I IasOc 0 Slalnless Steel D Other <br /> ' <br /> Grout Seal Depth rR D Neal Cement(94 Ih hagi5-10 get water) 0 Sand Cement sack mix17 gal water <br /> Y'Benlonite(20%solids) 0Other <br /> Grout Placement Method Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller D Pump Contractor 0 Other <br /> D Concrete Pedestal UDimenslons:Width_R Length It Thick in U Chrlety Box U Stove Pipe <br /> PUMP 0 SubmersibleO Turbine D Other HP Pump Set R Standing Water Level ft <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 /> MIN HOUR ADVAN TICE REQUIRED FDOR IN CT�NS-PLEASE CALL(209)53-7769 <br /> SIGNED <br /> 7 <br /> I <br /> ATE <br /> r"All <br /> F r <br /> qy O <br /> 17-7 A'4�[.1.11 . I I . I I k V-— <br /> o'goo <br /> 4-111 kjQ <br /> Fpq�l q�NTy <br /> MENT <br /> H+R+----4t-- --T� I I I <br /> DEPARTMENT USE ONLY <br /> l v lr C. <br /> AppllcationAccepted By �/ /�� Date SA <br /> ZaZ,; Area J Employee ION <br /> Grout Inspection By Dete ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Sall Boring Inspection By Dale Constructed Well Depth it <br /> COMMENTS <br /> PE Sc Received Checkf/ Amount Date Permit/ Invoice N Well IDK <br /> Codes Infoash Remitted S rvice Request d <br /> Ll v Sa_ e1 Z <br /> L 3q I s' • <br /> 7 <br /> EH013-00 0/01119 2 7 WELL/PUMP PERMIT <br /> - N <br />