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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT ww�A•.ajgoy.Org/ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS 44111 1 t,G iA Awty JC. CITYRIP C^ m <br /> CROSS STREET rii"t �d+t Q-1, APN I.11 13D-37—PARCEL S12E V•LANO USE APPLICATION <br /> OWNER NAME 7 t.JCtiKyS p C Q PHONE N <br /> OWNERADDRESS SSS Ck=Vi "CLA p `'�\V -`� CITY/STATE/ZIP �—�——1D UE '156114 <br /> CONTRACTOR "Ms <br /> "\x CacL'rr.�,�ri„�uc�t Jv.�\�Y1P1 PHONE .201-S6-54'40 <br /> r, <br /> CONTRACTOR ADDRESS `0 zrX %'A:;S r CITYISTATE21P 1•V"LA 1 '1153719 � <br /> SUBCONTRACTOR/CONSULTANT Msc. t'c\FC PHONE 4%lIk0 Ae(e;--0'k0'1 <br /> SUBCONTRACTOR/C ULTANT ADDRESS 00'% O"AO'U CIITYISTATIZIP W'slcll'iNV1FiNZD /CA <br /> LICENSE -57 0 C-61 C 0-09 D Other NUMBER LlZ7a''1� EXPIRATION DATE <br /> BILLING PARTY: 3 OWNER C CONTRACTOR UBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropene(4392)D Arsenic(4393) <br /> INTPNr1 ;LUZF D Domestic/Private G IrrigatiordAgricultural ❑Industrial D Water Quality Monitoring C Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner; Water System Name Contacl Name or Phone Number <br /> TYPE OF WORK C New Well 0 Replacement Well 7 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Boring(s) x of borings Geotechnical—9) #of borings <br /> 0 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump ❑Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method 0 Mud Rotary 0 Air Rotary 811uger 0 Cable Tool D Push Point 0 Other <br /> Proposed Well Depth AS ft Excavationt�" _in diameter ❑Open Bottom D Gravel Pack/Gravel Size in diameter <br /> C Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/GaugelASTM Schad D Steel 0 Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth al.�J ft 04at Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix17 gal water <br /> D Bentonite(20%solids) 0 Other <br /> Grout Placement Method 0 Pumped 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal DDimensions:Width ft Length It Thick in 0 Christy Box C Stove Pipe <br /> r1m, ❑SubmersibleD Turbine C Other HP _ Pump Set ft Standing Water Levei It <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. 1 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 /> WORKEO&IKNSATION LAWS. <br /> MINI U HO(LAll ANC) �JTI REQUIRED FOR INSPECTIONe EASE CALL(209)953-7697 <br /> SIGNED /�V �� � TITLE Dwner, DATE <br /> I <br /> V far";� <br /> I <br /> 1 <br /> I <br /> i <br /> ?p2� <br /> i 5S0i'0"1V-NCn1 <br /> MBjyT <br /> gEWARTMENT U E/0 LY <br /> Application Accepted By W, /VAVDate Z Z b � Area Employee ID# Vlel <br /> Grout Inspection By Date � SPECIAL Well Permit <br /> Pump Inspection By Date :: WAIVER Received <br /> Soil Boring Inspection By Date ! C1 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received I Check#/ Amount Date Permit/ Invoice# Well ID# <br /> C des Indo V. am to Service Request# <br /> Z i/11 <br /> EHD43-M e111Rd19 WELL(PUMP PERMIT <br />