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r \ <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)488. 420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> c 1! n <br /> JOB ADDRESS 3 t7 t7 O 3 a . �q>S O IL Iia. CITY/ZIP�r4CjJ <br /> jam] — D <br /> CROSS STREET D1AfIhdo, F*r4--y(` APN 2_55 2_76-0 PARCEL SIZE NA 7 LANG USE APPLICATION# p <br /> OWNER NAME Ger-,r'I``� A4,Wk'.^^ ,/PHONE &12,-*36(V'q <br /> OWNER ADDRESS �(A(AZO Peifn',A r'-d• CITYISTATEfZIP Md$VV�CC01 rAl '7$737 <br /> CONTRACTOR mASCl(W Dr\Ilon -TAC. PHONE 522-19Zo <br /> CONTRACTOR ADDRESS ►I 1 A Ib CITYISTATE/ZIP/r10=/ rt IMS2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATEIZIP <br /> LICENSE )f C-57 C C-61 J D-09 ❑Other NUMBER 6Q EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General MineraUColiform Bacteria(4391)C Dibromochloropropane(4392)o Arsenic(4393) <br /> INreNoeD USE D Domestic/Private Irrigation/AgricUltural 0 Industrial 0 Water Quality Monitoring n Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different I—Owner. Water System Name Contact Name or Prions Number <br /> TYPE OF WORK yNew Well 0 Replacement Well C Well Alteration/Modification D Other <br /> 0 Monitoring Well(s) #of wells C Soil Bohng(s) s of borkVs C Geotechnical •of borings <br /> C Out-Of-Service Well E Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> J New Pump C Pump Replacement C Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Rotary r J Air Rotary ❑Auger 0 Cable Tool C Push Point C Other <br /> of <br /> Proposed Well Depth yOO ft Excavation in diameter (Open Bottom J Gravel PacklGravel Size in diameter <br /> J Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter Ih in Thickness/Gauge/ASTM Schad 0•ZSO [)&eel 0 Plastic J Stainless Steel 0 Other <br /> Grout Seal Depth ' O It 7 Neat Cement(94 Ib bag15-10 gal water) $Sand Cement /0-:3 sack mixr7 gal water <br /> U Bentonite(20%solids) FI Other <br /> Grout Placement Method`If Pumped C Free Fall C Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller jd Pump Contractor 0 Other <br /> J Concrete Pedestal❑Dimensions:Width ft Length ft Thick in C Christy Box U Stove Pipe <br /> PUMP J Submersible Turbine 0 Other HP Pump Sel 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 /> MINI M�ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953.7697 <br /> SIGNED TITLE O L-'s'� DATE 7-41 <br /> -------------------------- <br /> -------------------------- <br /> MINT <br /> FD <br /> 2020 <br /> c <br /> N°�Nry <br /> rMENr <br /> DEPARTMENT USE ONLY ( / <br /> ,►^ '-Z'� Date y 1Z' Z��Z"o Area �r 7 Employee ID# �H <br /> Application Accepted By ` <br /> Grout Inspection By L'C-Date C SPECIAL Well Permit <br /> Pump Inspection By Date O WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> WELL/PUMP PERMIT <br /> EHD 43-00 aNtlt9 <br />