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WELL/PUMP PERMIT <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 /> JOBADDREsS 'E. n r CmrLP m�(�j}f.l.-la" S 33 m <br /> yy� ) /� D <br /> CROSSSTREET 1/t�!i1^AJPtI Jr IL--1 IDC)'' PARcFLSaE .( y LAND USE APPLICATION If Z 7 A <br /> OWNER NAME rn 7X� C 't ` PHONE `v 1dj�—✓�` 3 <br /> OWNER ADDRESS �r51 CrrY/STATEIZIP /ry Cr;l�I LLj I FI �S 3•j{.- <br /> CONTRACTOR 1 V /lIPHONE Lp4--S !)[y-3q,5,( <br /> CONTRACTOR ADDRESS �)C C^"� CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE _ C-57 tebI D-09 Other •�1 NUMBER ExPIRArloN DATE — <br /> DOMESTIC WELL SAMPLING:-General MineralfColiform Bacteria(4391) Dibromochloropropane(4392)-Arsenic(4393) <br /> INTENDED USE - omestic/Privale -Irrigation/Agricultural -Industrial Water Quality Monitoring -Soil Sampling/Characterization <br /> -Public Water System <br /> I(diRer�enl from Owner Wale,System Name Contact Name or Phone Number <br /> TYPE OF WORK e5 w Well ?placement Well Well Alteration/Modification :.:Other <br /> -Monitoring Well(s) #of wells -Soil Bonng(s) u01b drgs - Geotechnical <br /> -Out-Of-ServicL Well -Out-Of-Service Well Renewal -:Cross-Connection Repair <br /> New Pum - Pump Replacement - Pump Repair -Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _.Mud Rotary Air Rotary Auger Cable Tool -.Push Point - Other <br /> Proposed Well Depth It Excavation in diameter -Open Bottom _Gravel Pack/Gravel Size in diameter <br /> -Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in ThicknesslGaugelASTM Sched -Steel Plastic Stainless Steel _I Other <br /> Grout Seal Depth ft Neal Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mixr7 gal water <br /> -Bentonite(20%solids) _Other <br /> Grout Placement Method -Pumped Free Fall _Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller -Pump Contractor - Other Lve <br /> -Concrete Pedestal_Dimensions.Width ft Length R Thick in -Christy Box -Stove Pipe <br /> PUMP ubrnersible:Turbine -Other HP Pump Set L7 7. 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 w <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL /� ^ <br /> WORKERS COMPENSATION LAWS. <br /> AD NCE NOTICE REQUIRED FOR INSPECTION -PLEASE CALL(209)953-7697 c NT <br /> }y� y <br /> SIGNED �"'vV- `- _ TITLE N'� �ti�"Y1 y' `�W I'1•� �� DATE �,6 <br /> F 2000 <br /> q Qvi <br /> T RAN N <br /> coo <br /> NTy <br /> FNT <br /> l <br /> I <br /> l � 1 <br /> DEPARTMENTUS ONLY 'I <br /> Application Accepted By ! �l. L Date 1`t `- Area ) / Employee ID# <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By 1�(^'414 ! 2 S[Zic Yu L,Date Z G WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#1 Amount Permit/ <br /> Codes Info Cash Remitted Date e request# Invoice# Well 10# <br /> EHD 43-06 r.hud atate �/'�/��� WELL IPUA1P cFRMR <br />