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-� WELL/PUMP PERMIT <br /> SAN 313AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -(209)468-3420 <br /> NON-REFUNDABLE/PEgRMITp (� CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> FCROSSSTREET- <br /> / /O a �1.�-Vl�` CITYIZIP k <br /> 13enec Imo-+' 1 ti APN 1d3-If I I�O PARCEL SIZE �� LAND USE APPPLLIICATION#p A lt- " �P`�HONEYOo-8f 1,ae5�SS CITYISTATEIZIP 6CKr " l <br /> CONTRACTOR •-WP�!�s ✓r�" lei ,P�H�ONE �,� 2-I ,Z, <br /> 1nW <br /> CONTRACTOR ADDRESS )-f �F CITYISTATEIZIP r/ 5�f1 <br /> SUBCONTRACTOR # PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> LICENSE C-57 D C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE7011 <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE 0 DomesliclPrlvale Irrigation/Agricultural 0 Industrial O Water Quality Monitoring C]Soil Sampling/Characterization <br /> 0 Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 9 New Well 0 Replacement Well 0 Well Alteraliort/Modificalion 0 Other pot borings <br /> 0 Monitoring Wells) #of wells ❑Soil Boring(s) R of borings 0 Geotechnical <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal D Cross-Connectlon Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary D Air Rotary 0 Auger 0 Cable Tool 0 Push Point ❑ Other <br /> Proposed Well Depth -IM It Excavation 1.5 In diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter.f In Thickness/Gauge/ASTM Sched 24C — ❑Steel klastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth ." ft 0 Neal Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ;13enlonite(20%solids) 0 Other <br /> Grout Placement Method X Pumped 0 Free Fall ❑Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By n Driller ❑Pump Contractor ❑ Other <br /> 0 Concrete Pedestal ODimenslons:Width ft Length ft Thick in 0 Christy Box ❑Stove Pipe <br /> PUMP 0 Submerslble0 Turbine D 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 <br /> ORDINANCES, <br /> URRENT AND ACTIIVEWITH'THECALIFORNIA CONTRACTORS NSTATE U ICEINSE BOARD AND ONS. I ALSO TITHAT I AM N COMPLIANCE LICENSEFY THAT MY REQUIRED <br /> CWITH ALL <br /> COMPENSATION LAWS. <br /> woRKe MIN MUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)0 953-7697 <br /> l L C � TITLE D,',I IL DATE <br /> SIGNED 1 <br /> h Q <br /> H o <br /> P TMENT USE ONLY 9RTyF< <br /> "Tlid <br /> yy <br /> Date � Area*OPECTIAL <br /> Employee ID# <br /> y. <br /> Application Accepted By Well Permit <br /> Grout Inspection By Date <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By <br /> Dale Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received C eC I Amount Date Permit/ Invoice# Well ID# <br /> Info B ash <br /> Coes Remitted Service Re uest# <br /> � <br /> WELL/PUMP PERMIT <br /> EHD 43-06 8101118 <br />