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WELL/PUMP PERMIT <br /> SAN JOAQU IN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT wwwsiciov.oralohd EXPIRES_1 Y/EARP FROM DATE ISSUED <br /> JOB ADDRESS Ad <br /> CITYZP <br /> 1; 3 <br /> /y, <br /> CROSS STREET APN ��// V�3� PARCEL SUE ��y` LAND USE APPLICATION A O <br /> 4ft�) <br /> OWNER NAME T/PHONE i d <br /> OWNER ADDRESS 5W! Pj (�qla44r AZyy_L�' CITYISlATEZP <br /> CONTRACTOR Q Lw)Q 5 421y - PRONE <br /> CONTRACTOR ADDRESS CP-1 3-1-0 _ CITYISTATE2IP � �`�QIV <br /> SUBCONTRACTORICONSULTAW_ / PHONE 44 <br /> SUBCONTRACT /CONSULTANT ADDRESS Q YISTATE/ZJP <br /> LICENSE V57 C-bI LW9 Ouw NUMBER EYPIRATDN OATS <br /> �D PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/COhform Bacteria(4391) D:bronnochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomasticIP—le Irrigation/AgneuKural Industrial Water 0-10y Mondonng Soil SamplinWCharacienzanor <br /> Public Water System <br /> II dflarent born Ower. Water System Name Cantata Nerne Cr Phone Number <br /> TYPE OF WORK New Well Replacement Well Well AlterationJAJodi8n6on Other <br /> Monitoring'M6(s)_-_0 of wells Soil Bonno(s) S olbatnps nAnlAchn{raI ° 'nonn�c <br /> Out-Of-Serme Well ,Put-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump PumpR, cPWcemern �Repair _ _ Raise Well Casing _ <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Dcpth n Excavation In diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diametar / Conductor Casing Deput n <br /> Weil Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth fl Neat Cement(94 lb bag/5-10 gal wated Sand Cement sack—17 gar water <br /> Rpntonde(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed eV Dnik r Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width_ft Length R Thick in Christy Box Stove Pipe <br /> P MP Submersible Turbine Other HP Purnp 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 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 COMPEbISATION LA <br /> ,faCe N0 it; .. r uR 1PIPPEC MONS-PLEASE CALL(269)95z 69'j <br /> SIGNED /r rG�� TITLE DATE I <br /> T 7 <br /> ILI <br /> I ii I I <br /> i <br /> -- MF�VT <br /> - - 1c, <br /> F/VED <br /> g ?O2� <br /> i M U/N <br /> C UN <br /> EN �, <br /> PgRTM�NT <br /> �i DEPARTMENT USE;ONL <br /> Application Accepted BY r Li Date Area rx GI`� Employee IDie DA- <br /> Grout <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date ( WAIVER Rec6lved <br /> Sod Boring Inspection By Date_ Constructed Well Depth ft <br /> COMMENTS _ <br /> PE SC Rieeelwd Amount ata Permit/ Invoice N Wall IDA' <br /> Godes InfD By ash Romitted I I Service ReouestN <br /> 05� p y7 ' <br /> FHD.sae en1I201e N['-x—.11 Enun <br />