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WELL/PUMP PERMIT <br /> t• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT G www.Mgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J\1 t- CU)I 1 C t^ /S r/ CITYr111••'\P Ctij N V O <br /> CROSS STREETIG-4 e/or S TIC f c%(Ir%c y)4 r APN 0(1 5 - Z,J /�]O J7 PARCEL SIZE 3-I LAND USE APPLICATION A A <br /> OWNERNAME I\ o!L (- 1 eJ.C�tf'cc PHONE <br /> OWNER ADDRESS (� CITY/STATE/DP ] Q <br /> CONTRACTOR �/:{)` t/�.�7 �71,_J 1 I n 9 PHONE J�Iet <br /> CONTRACTOR ADDRESS �'C F)C.x 9 CITY/STATEZP GSI <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATEMP <br /> LICENSE XC-57 C-61 D-09 Other NUMBER',?-113S3 EXPIRATION DATE 7—3 I_ �•' <br /> BILUNG PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT PAN <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) a i; <br /> _INTENDED UsE DomestirJPrivete Irrigation/Agricultural Industrial Water Duality Monitoring Soil Sampling/Characterizaaon ,VPA <br /> Public Water System Mq v <br /> I(different from Owner Weter Syatem Namm <br /> Name Contact Nae or Phone Numer Rb (' ��?0 <br /> TYPE OF WORK )4 New Well Replacement Weft D Well Alteration/Modificalion Other J0 II'' ,f <br /> e of bonnga t or bonnge VI <br /> Monitoring Well(s) f of wets Cl Soil Boring(s) Geotechnical ENS//RON N cowls <br /> Out-Of-Service Well Ll Out-Of-Service Well Renewal Cross-Connection Repair LT//D, P,p �1_ 7' <br /> New Pum Pu Replacement D Pum Repair Raise Well Casing /.t <br /> WELL CONSTRUCTION MFNT <br /> Drilling Method?Pk Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth2A fft Excavation�_in diameter Open Bottom ')(Gravel Pack/Gravel Size-4:--in diameter <br /> Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter f,,__in Thickness/Gauge/ASTM Sched Steel �(Plastic Stainless Steel Other <br /> Grout Seal Depth co ft Neat Cement(94 f6 Dag/5-10 gal water) Sand Cement I 10-:7 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped .:Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By�fter Pump Contractor Other <br /> Concrete P destal Dimensions:Width ft Length n Thick in i Christy Box Stove Pipe <br /> PUMP )k Submersible Turbine Other HP Pump Set ft Standing Water Level it <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> MINIMUNJ 48 OUR ADVANCE NOTICE REQUIRED FOR�1'INSPECTII7ONS-PLEASE CALL(209)7953-769- <br /> SIGNED— TITLE -t j I A� DATE <br /> W <br /> qt I Fe I f <br /> S <br /> e <br /> DEPARTMENT 4SE #ONLY ''JJ <br /> Application Accepted By ;;?7/--Z-:: Date S ZS ZOZQ Area �C Employee IDX -<,t'F�tY� <br /> Grout Inspection By q ( <br /> Date 1AA la-1- 1 PECIAL Well Permit <br /> Pump Inspection By C,&L t��a �./t`ti kt,Dale C(��1D9-C WAIVER Received <br /> Soil Boring I ton By Date Constructed Well Depth it <br /> COMMENTS <br /> r <br /> '�C•I<Plf D tl. <br /> PE sC Receiv Check#! Amount Permit/ Invoke 0 Well ION <br /> Codes Info Remitted Service Requestf <br /> HHS- <br /> 70 <br /> EHO43-06 WELL RUMP PERMIT <br />