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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT I 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-8232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW.S Ov.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 'f / J`"S"y J'f CrTV/T1P 7ze—cY <br /> A <br /> CROSS STREET 1f J APN /��'-�/�' �+ PARCEL SIZE�J' LAND USE APPLICATION# 4� <br /> - <br /> 1 Zd G <br /> OWNER NAME �71 1, il.' 100-44-N N S PHONE <br /> OWNERADDRESS CRYISTATFMP 1774-- <br /> ' <br /> CONTRACTOR `IcJ cIA.)Z Q't /�Y-"5 PHONE <br /> 7 <br /> CONTRACTOR ADDRESS / / ''SJ� ce,'L+ CITy/STATE0P 50:yrdAy— CR ` •Y v " <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/SSTATEMP <br /> LICENSE A C-57 ❑C-61 U D-09 U Other NUMBER -1.5-7'/f EXPIRATON DATE <br /> BILLING PARTY: I ❑OWNER U CONTRACTOR 0 SUBCONTRACT CONSULTANT <br /> DoMEsnc WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibrornc hloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private r Irrigation/Agricultural 0 Industrial ❑Water Qk allty Monitoring 0 Sail Sampling/Charactenzation <br /> 0 Public Water System <br /> If dfrerent from Cv ner. Water System Name Canted Nemo or Phone Number <br /> TYPE OF WORK A New Well C Replacement Well ❑Well Alteration/ModficationD Other <br /> ❑Monitoring Wells) #of wells ❑Soil Boring(S) p of borIngs ❑Geotechnical f of bodngs <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renew I ❑Cross-Connection Repair <br /> 0 New Pump ❑Pume Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTIONDrilling . <br /> e Tool <br /> Proposed Well Depth Rotary OTI J2 D ft r Rota��oger(x Cabin diameter0 POD O int <br /> ntBottom Other I�Gravel Pack/Gravel Sino .'�.� in diameter <br /> 'Conductor Casing cs in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad St el C Plastic 0 Stainless Steel ❑Other <br /> Grout Seal Depth ft 0 Neat Cement(94 lb bagl5-10 gal water) Sand Cement b-Sae sack mW7 gal water <br /> 0 Bentonite(20%solids) ❑Other <br /> Grout Placement Method 0 Pumped ❑Free Fall 0 Other 0 Rc tardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ump Contractor ❑ Other <br /> 0 Concrete Pedestal ODimenslons:Width ft Length ft Thick In ❑Christy Box ❑Stove Pipe <br /> PUMP 0 Submersibl, • Lrbine 0 Other HPimp Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT T IF WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIO S. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICEN BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUMOUR 'Di, VANCE NOTICE REQUIRED FOR INSP CTIONS-PLEASE CALL(2D95 97/=e20 <br /> SIGNED � TITLEDATE- <br /> c <br /> qy <br /> Fc IFN <br /> ✓�N F�VF� <br /> 0 <br /> DEPARTMENT USE <br /> r NLY MFNT <br /> Application Accepted By �/ - ' Dare C -� Area l' �^C� Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> .Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permftl Invoice# Well ID# <br /> Codes Info 8 as Remitted Dare rviceRe uest# <br /> VjSx �y <br /> p <br /> -06 6/11 r101a <br /> WELL/PUMP PERMIT <br /> EHD 43 <br />