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r • <br /> SAN.JOADUIN COUNTY ENVIRONMENTAL HEALTH DEPAR WELUPUMP PERMIT <br /> 1868 EAST HAZ,ELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS z/ CrrYlZIP uj;J)-v y <br /> CROSS STREET APN 1 <br /> PARCE�STAT—P <br /> LSIZE -1�LAND USE APPLICATION# p <br /> O PHONE ON-OWNER NAME N — t/OWNER ADDRESS 1 1 I CI � _' 7 <br /> CONTRACTOR PHONE 1 19 7-f7 <br /> -A ICONTRACTOR ADDRESS CITYISTATE/ZIP 5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrryISTATEIZIP <br /> LICENSE C-57 L C-61 L D-09 ❑Other NUMBER Wt(V2 _ EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)L Dibromochloropropane(4392)F.Arsenic(4393) <br /> INTENDED USE i0 DDmesbc(Pfivale Irrigation/Agricultural 0 Industrial Water Quality Monitonng ❑Soil Sampling/Characterization <br /> J Public Water System <br /> If difleroM horn Owner Water System Name CwW Name or Pion Number <br /> TYPE OF WORK New Well ❑Replacement Well II Well Atteration/Modification L Other <br /> 7 Monitoring Wells) #of wells IJ Soil Bortng(s) a or boring` 7 Geotechnical s a bmnps <br /> Out-Of-Service Well J Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> L New Pump 0 Pump Replacement Pump Repair 0 Raise Well Casing <br /> WEL!COIISTRUCTION <br /> Drilling Method AMudto L Air Rotary L Auger II Ca 0 L <br /> Cable Tool Push Point <br /> r6r Other <br /> Proposed Well Depth �`� fl Excavation in diameter L Open Bottom I Gravel Pack/Gravel Silld in diameter <br /> F_Conductor Casing in diameter I Conductor.asing Depth .��Jff_tl <br /> Well Casing Diameter r in ThickneWGauge/ASTM Schad 2UU C Steel XPlastic 7 Stainless Steel ❑Other <br /> Grout Seal Depth it i Neat Cement(94 Ib bag/5-10 gat water) 7 Sand Cement sack mix/7 gal water <br /> Bentonitit(20%solids) ❑Other <br /> Grout Placemen thod Pumped 7 Free Fall J Other rL Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor n Other <br /> Concrete Pedestal❑Dimensions Width_fl Length it Thick in -Christy Box 7 Stove Pipe <br /> PUMP "Submersible�'Turbine [ Other HP Pump Set R Standing Water Level <br /> 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. 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 /> MI (1rDVANCE NOTICE REQUIRED FO PECT/I)�_NS-P EA E CALL(209)953-7697 <br /> SIGNED 1 TITLE I �1 O��vr DATE <br /> 1, <br /> --------------- <br /> -------------- <br /> Iv 13111 V <br /> PAM <br /> RE E <br /> N AQ A <br /> SA EN <br /> ID <br /> . HEA H <br /> DEPARTMENT USE ONLY <br /> i rt <br /> Application Accepted By `r- C� Data - - �-i,, .1 Area C 5[7'J Employee ID# <br /> Grout Inspection By/ Date -7–i7– ❑ SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> rPE SC Recelved Checkil Amount Data PermluInvoice# Well ID# <br /> Indo ,Cash Remitted Service Raquest# <br /> EHD4106 8MI119 /�/,/����� WELL IPUMP PERMIT <br />