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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 />m n.cFYPIRFR 1 VF•R FRr1M nATF ISSUED <br />NLJN-KthUNUAt$Le r CRml1 <br />JOB ADDRESS C I CITY/Zip <br />CROSS STREET SO Y APIN (iV1' � V O�v PARCEL SIZE LAND USE APPLICATION III— <br />OWNER <br />OWNEP. NAMEa, AN k/- PHONE <br />OWNER ADDRESS I V . CITY/STATEIZIP <br />CONTRACTOR ft�s` ' PO�N�E`�^1� {i✓ '" 1 ✓ 1/ <br />CONTRACTOR ADDRESS \ CITY/STATFJZIP'�\oytjn `l/ r �� • �_ <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br />LICENSE C-57 C C-61 7, D-09 L Other NUMBER EXPIRATION DATE—Q4- <br />DOMESTIC WELL SAMPLING:A General Mineral/Coliform Bacteria (4391))(Dibromochloropropane (4392); i Arsenic (4393) <br />INTENDED USE omestWPrivate C Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Soil Sampling/Charactenzahon <br />U Public Water System <br />If diBerenl from Owner: Water System Name Ccmact Name or Phone Number <br />TYPE OF WORK ew Well ❑ Replacement Well ❑ Well Alteration/Modification Other <br />C Monitoring Wells) # of wells ❑ Sod Bonng(s) 8 of borings C Geotechnical s of borings <br />C Out -Of -Service Well ❑ Out -Of -Service Well Renewal :) Cross -Connection Repair <br />C New Pum C Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION// Sq <br />Drilling Method W'<d Rota Air Rotary D Auger ❑ Cable Tool Push Point ❑ Other i( �/ <br />Proposed Well Depth. _ft Excavation _a_-_ in diameter ❑ Open Bottom N Gravel Pack/Gravel Size t <br />5 Conductor Casing in diameter / CondjLtb Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched0 ❑Steel Plastic ❑ Stainless Steel D Other <br />Grout Seat De in ft C Neat Cement (94 /b bag/Cr10 gal water) C Sand Cement sack mix17 gal water <br />Bentonite 0% solids) Other <br />Grout Placement Method Pumped C Free Fall ❑ Other U Retardant / Accelerator (name) <br />PEDESTAL Installed By ':; Dnller C Pump Contractor f:I Other <br />C Concrete Pedestal IlDimenslons: Width It Length It Thick in Chrlsty Box D Stove Pipe <br />iPUMP ..-' Submersibles Turbine L Other HP Pump Set ft Standing Water Level It <br />ncnr_cT 11=111rr 1111 1 HAvt rKtt AHtU THI5 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 />DEPARTMENT USE ONLY vL <br />/ r <br />Application Accepted By-- Data v rX ,J Area IqCl Employee ID# - <br />GroutlnspectionBy - Date It2/i�_-2G C7iPECIAL Well Permit <br />Pump Inspection By Dale WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth "L$J / ft <br />COMMENTS U �e {i�iL i._n l,r L{ Z l h" SA /-^ Q <br />F yME <br />VFO <br />U� <br />06 <br />20?0 <br />4 QUIN <br />lotvMRTo c�rY <br />MFNr <br />I <br />J <br />An - <br />WELL /PUMP PERMIT <br />