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WELIJPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTNENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT Q], www.s ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' IJOa ADDRESS F w . rT7hc� r. CITYlzIp"�Qh�cV 9533 N <br /> 1 ' ^�/ A Y� (. A a <br /> CROSS STREET`i,+v CIk- �Y►F�Cr�� ^A1'r'r 2Ig Q 2A-`ITPARCEL SQE'v D USE APPLICATION#�C� o <br /> OWNER NAME YQr�c-q%r„�, 1Q�C��O 15. L L�+ PHONE�O O2QA • N <br /> OWNERADDRESS ��+� J+ I VC�ITYYIIS�TATFJLP Cromer 9C <br /> CONTRACTORI O r• J. PHONE <br /> CONTRACTOR ADDRESS 19 <br /> I L OLdd CRY/STATE21PMo d C547o est 9 53 5 to <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATERIP <br /> LICENSE Y.0-57 C-61 D-09 . Other NUMBER 2-90813 EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR 1 SUBCONTRACTOR/CONSULTANT <br /> Dowsnc WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)C Dibromochloropropane(4392)Ci Arsenic(4393) <br /> INTENDED USE C Domestic/Private11 gation/Agricultural ❑Industrial Water Quality Monitoring r- Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contact Name N Phone Number <br /> TYPE OF WORK XNew Well t Replacement Well J Well Alteration/Modification i Other <br /> Monitoring Well(s) #of wells 7 Soil Boring(s) a of bones "Geotechnical #of borbVs <br /> Out-Of-Seance Well 7 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement U Pump Repair :-Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary �Auger ❑Cable Tool '. Push Point Other <br /> Proposed Well epth_2X 0 it Excavation 2_0 in diameter Open Bottom Gravel Pack/Gravel Size 42 in diameter <br /> _;Conductor Casing in diameter / Conductor Casing Depth__ tt <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 5 ;l Steel Plastic �Stainless Steel 1 Other <br /> Grout Seal Depth mit G Neat Cement(94 Ib bag/5-10 gar water) 'Sand Cement . _sack mixf7 gal water <br /> Bento 'te(2,0%solids) Other " <br /> Grout Placement Method roped i�Free Fall ❑Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By I,Driller Pump Contractor Other <br /> Concrete Pedestal'Dimensions:Width R Length ft Thick In n Christy Box 1 Stove Pipe <br /> uaa Submersible Turbine ❑Other HP Pump Set R Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> A 48 HOUR ADVANCE NOTICE RL TIONS-PLEASE CALL(209)95:3- n <br /> SIGNED DATE y _ G.L_�.A/^ <br /> NT <br /> ED <br /> I IX <br /> 20 <br /> IT / <br /> DEPARTMENT SE ONLY ,y� J TMFNT <br /> Application Accepted By Date �� S ,'J;L-) Area 5 l r fC;11 TCe L Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date CI WAIVER Received <br /> Sal Boring Inspection y Date Constructed Well Depth it <br /> COMMENTS C i OIVY de kl ifrt' D f OV i r Ca D!J 10�I I <br /> PE aC Received Ch Amountat Permit/ Invoice# Well ID# <br /> Codes bdo Rendtted Fail <br /> Service Re ue It# <br /> EM 43-M 6111=19 WELL 1PUMP PERMIT <br />