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I WELL/PUMP PERMIT I< / <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 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 /> ` to <br /> JOB ADDRESS P L 13 P�T_P OL C P CITY/ZIP 'fit"aO-SI <br /> W, <br /> .'� �/ �J1 .y `J D <br /> CROSS STREET W_, F.O��Q Ce- FAAPN L.�,�yQ T PARCEL SIZE1.5'S LAND USE APPLICATION# 'jam A <br /> OWNER NAME ty\a ],,tj,'L" T�{JSQ,S PHONE <br /> OWNER ADDRESSLa�2Z�sZ ��+(\\r�-�'P �n CITYISTATEIZIPt� <br /> � �V Cfl `ti..7� 1- - <br /> CONTRACTOR La., PHONE <br /> CONTRACTOR ADDRESS CITYISTATEZP.rn <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/7JP r <br /> LICENSE C-57 D C-61 ❑D-09 0 Other NUMBER ICII)9L3- EXPIRATION DATE <br /> DOMEsnc WELL SAMPLING:-General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)':,Arsenic(4393) <br /> INTENDEO USE Domestic/Private D IrrigationlAgricultural D Industrial G Water Quality Monitoring it Soil Sampling/Characterization <br /> ^:PUblic Water System <br /> If dilterem from Owner r Wet System Name Comad Name or Phone Number <br /> TYPE OF WORK>(New Well eplacement Well 0 Well Alteration[Modification Other <br /> :]Monitonng ell(s) #of wells D Soil Bonng(s) a of bonne. C Geotechnical a of bonngs <br /> 0 Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> New Pump C Pump Replacement E Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary ��^Airxir`` t .i Auger Cable Tool G Push Point Other <br /> Proposed Well Depth _�R' cavation 4.4n diameter U Open Bottom Gravel Pack/Gravel Size_ n diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thickn auge/ASTM Schede 11 Steel Plastic C Stainless Steel 0 Other <br /> Grout Seal eepth� fl Feat Cement(94 1b bag/5-10 gat water) C:'.Sand Cement sack mix/7 gal water <br /> a.Bentonite(20%solids) a Other <br /> Grout Placement Method Pumped 0 Free Fall i:;Other "Retardant/Accelerator(name) <br /> PEDESTAL Installed By 7 Driller ump Contractor i7 Other <br /> Concrete Pedestal CDi ension .Wdth ft Length ft Thick in Christy Box C Stove Pipe <br /> PUMP 'I SubmersibleC Turbine '-1 Other HP Pump Set ft 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 /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRE NSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED Nk - b ITLE NLQ" DATE <br /> will"I <br /> r <br /> F <br /> DE ARTMENT USE ONLY <br /> Application Accepted By / Date Areae Employee ID#f-"�+'--`-"� <br /> Grout Inspection By YY Date l! a�J' C] SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Vyell Depth ft <br /> COMMENTS <br /> PE Sc Received a k#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> g <br /> Sy /� <br /> 1 r <br /> EHD 43-06 8101116 WELL 1PUMP PERMIT <br />